- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.43 / $407.43 / $865.79
| Facility | | $407.43 | $407.43 | $865.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.02 / $330.02 / $330.02
| Professional | | $330.02 | $330.02 | $330.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $264.82
| Professional | | $162.97 | $162.97 | $264.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.43 / $407.43 / $411.50
| Professional | | $407.43 | $407.43 | $411.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.43 / $407.43 / $660.04
| Facility | | $407.43 | $407.43 | $660.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.02 / $330.02 / $407.43
| Professional | | $330.02 | $330.02 | $407.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.46 / $244.46 / $611.15
| Professional | | $244.46 | $244.46 | $611.15 |