- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.97 / $310.97 / $310.97
| Professional | | $310.97 | $310.97 | $310.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.33 / $217.58 / $567.63
| Facility | | $173.33 | $217.58 | $567.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.88 / $310.97 / $310.97
| Professional | | $304.88 | $310.97 | $310.97 |
- 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
- $310.97 / $310.97 / $372.57
| Professional | | $310.97 | $310.97 | $372.57 |
- 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
- $304.88 / $304.88 / $442.08
| Professional | | $304.88 | $304.88 | $442.08 |