- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $384.47 / $384.47 / $384.47
| Facility | | $384.47 | $384.47 | $384.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.58 / $307.58 / $384.47
| Professional | | $307.58 | $307.58 | $384.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.80 / $326.80 / $411.00
| Facility | | $326.80 | $326.80 | $411.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.80 / $326.80 / $326.80
| Professional | | $326.80 | $326.80 | $326.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.58 / $384.47 / $448.70
| Facility | | $307.58 | $384.47 | $448.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.39 / $320.39 / $1,460.99
| Professional | | $320.39 | $320.39 | $1,460.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.39 / $320.39 / $376.78
| Professional | | $320.39 | $320.39 | $376.78 |