- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.62 / $309.62 / $309.62
| Facility | | $309.62 | $309.62 | $309.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.51 / $270.51 / $309.62
| Professional | | $270.51 | $270.51 | $309.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $277.02 / $277.02 / $277.02
| Facility | | $277.02 | $277.02 | $277.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.02 / $277.02 / $277.02
| Professional | | $277.02 | $277.02 | $277.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.70 / $277.02 / $277.02
| Facility | | $263.70 | $277.02 | $277.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.02 / $277.02 / $277.02
| Professional | | $277.02 | $277.02 | $277.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.60 / $271.60 / $271.60
| Professional | | $271.60 | $271.60 | $271.60 |