- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $296.27 / $296.27 / $296.27
| Facility | | $296.27 | $296.27 | $296.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.30 / $296.27 / $296.27
| Professional | | $289.30 | $296.27 | $296.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Professional | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.69 / $128.69 / $169.82
| Facility | | $128.69 | $128.69 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.69 / $128.69 / $128.69
| Professional | | $128.69 | $128.69 | $128.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.31 / $259.31 / $296.27
| Professional | | $259.31 | $259.31 | $296.27 |