- 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
- $309.03 / $309.03 / $354.81
| Professional | | $309.03 | $309.03 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $891.25 / $891.25
| Professional | | $758.58 | $891.25 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $288.40
| Facility | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $346.74 / $436.52
| Professional | | $309.03 | $346.74 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $575.44
| Facility | | $331.13 | $331.13 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $323.59
| Professional | | $309.03 | $309.03 | $323.59 |