- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.61 / $310.61 / $310.61
| Facility | | $310.61 | $310.61 | $310.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.64 / $310.61 / $516.52
| Professional | | $299.64 | $310.61 | $516.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.41 / $257.77 / $346.78
| Facility | | $212.41 | $257.77 | $346.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.41 / $298.30 / $298.30
| Professional | | $270.41 | $298.30 | $298.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.61 / $310.61 / $310.61
| Facility | | $310.61 | $310.61 | $310.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.56 / $310.61 / $310.61
| Professional | | $122.56 | $310.61 | $310.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.27 / $298.30 / $298.30
| Professional | | $284.27 | $298.30 | $298.30 |