- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $398.11
| Professional | | $346.74 | $346.74 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $275.42 / $407.38
| Facility | | $213.80 | $275.42 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Professional | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $223.87 / $223.87
| Professional | | $97.72 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $295.12 / $416.87
| Professional | | $263.03 | $295.12 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Professional | | $346.74 | $346.74 | $346.74 |