- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.45 / $273.45 / $341.81
| Facility | | $273.45 | $273.45 | $341.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.00 / $237.60 / $273.45
| Professional | | $216.00 | $237.60 | $273.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.34 / $193.34 / $193.34
| Facility | | $193.34 | $193.34 | $193.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.34 / $273.45 / $273.45
| Facility | | $193.34 | $273.45 | $273.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $283.41 / $283.41 / $283.41
| Facility | | $283.41 | $283.41 | $283.41 |