- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.12 / $306.12 / $428.57
| Facility | | $306.12 | $306.12 | $428.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.12 / $306.12 / $306.12
| Professional | | $306.12 | $306.12 | $306.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.51 / $275.51 / $413.27
| Facility | | $275.51 | $275.51 | $413.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.51 / $275.51 / $281.02
| Professional | | $275.51 | $275.51 | $281.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.20 / $260.20 / $260.20
| Facility | | $260.20 | $260.20 | $260.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.20 / $260.20 / $260.20
| Professional | | $260.20 | $260.20 | $260.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.10 / $255.10 / $318.88
| Professional | | $255.10 | $255.10 | $318.88 |