- 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 / $562.34
| Professional | | $331.13 | $331.13 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $389.05 / $389.05
| Professional | | $331.13 | $389.05 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Facility | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $467.74
| Professional | | $331.13 | $331.13 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $269.15 / $630.96
| Facility | | $269.15 | $269.15 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Professional | | $331.13 | $331.13 | $331.13 |