- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $280.50 / $297.33 / $297.33
| Facility | | $280.50 | $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
- $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
- 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
- $302.00 / $302.00 / $302.00
| Professional | | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.25 / $300.25 / $378.32
| Professional | | $300.25 | $300.25 | $378.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.50 / $280.50 / $280.50
| Professional | | $280.50 | $280.50 | $280.50 |