- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.15 / $391.15 / $421.50
| Facility | | $391.15 | $391.15 | $421.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Professional | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $434.41 / $434.41 / $434.41
| Facility | | $434.41 | $434.41 | $434.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Professional | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Facility | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Professional | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $173.55
| Professional | | $143.31 | $143.31 | $173.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.15 / $391.15 / $421.50
| Facility | | $391.15 | $391.15 | $421.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $421.50
| Professional | | $143.31 | $143.31 | $421.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.43 / $140.50 / $203.73
| Professional | | $119.43 | $140.50 | $203.73 |