- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.33 / $297.33 / $297.33
| Facility | | $297.33 | $297.33 | $297.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.33 / $297.33 / $297.33
| Professional | | $297.33 | $297.33 | $297.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.23 / $488.26 / $900.79
| Facility | | $331.23 | $488.26 | $900.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.50 / $280.50 / $311.87
| Professional | | $280.50 | $280.50 | $311.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.48 / $326.48 / $326.48
| Facility | | $326.48 | $326.48 | $326.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.48 / $326.48 / $326.48
| Professional | | $326.48 | $326.48 | $326.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.25 / $342.80 / $360.30
| Professional | | $300.25 | $342.80 | $360.30 |