- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.97 / $310.97 / $310.97
| Facility | | $310.97 | $310.97 | $310.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $310.97 / $310.97
| Professional | | $300.00 | $310.97 | $310.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $603.22 / $732.04 / $984.82
| Facility | | $603.22 | $732.04 | $984.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.97 / $310.97 / $310.97
| Facility | | $310.97 | $310.97 | $310.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.97 / $310.97 / $310.97
| Professional | | $310.97 | $310.97 | $310.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.15 / $304.88 / $304.88
| Professional | | $143.15 | $304.88 | $304.88 |