- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.33 / $297.33 / $297.33
| Facility | | $297.33 | $297.33 | $297.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.33 / $297.33 / $448.96
| Professional | | $297.33 | $297.33 | $448.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.12 / $527.62 / $935.72
| Facility | | $373.12 | $527.62 | $935.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.80 / $349.80 / $349.80
| Professional | | $349.80 | $349.80 | $349.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.48 / $326.48 / $326.48
| Facility | | $326.48 | $326.48 | $326.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.48 / $326.48 / $326.48
| Professional | | $326.48 | $326.48 | $326.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.33 / $297.33 / $425.18
| Facility | | $297.33 | $297.33 | $425.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $406.00 / $406.00 / $406.00
| Professional | | $406.00 | $406.00 | $406.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.25 / $349.80 / $360.30
| Professional | | $300.25 | $349.80 | $360.30 |