- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $276.42 / $310.61 / $310.61
| Facility | | $276.42 | $310.61 | $310.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.30 / $310.61 / $310.61
| Professional | | $303.30 | $310.61 | $310.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $298.30 / $298.30 / $298.30
| Facility | | $298.30 | $298.30 | $298.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.30 / $298.30 / $298.30
| Professional | | $298.30 | $298.30 | $298.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $272.32 / $310.61 / $611.91
| Facility | | $272.32 | $310.61 | $611.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.61 / $310.61 / $310.61
| Professional | | $310.61 | $310.61 | $310.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.05 / $298.30 / $401.36
| Professional | | $298.05 | $298.30 | $401.36 |