- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $761.75 / $761.75 / $820.85
| Facility | | $761.75 | $761.75 | $820.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $341.47 / $366.53
| Professional | | $328.34 | $341.47 | $366.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.02 / $365.02 / $1,040.51
| Facility | | $292.02 | $365.02 | $1,040.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $340.72
| Professional | | $328.34 | $328.34 | $340.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $324.80 / $328.34 / $752.25
| Facility | | $324.80 | $328.34 | $752.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $328.34
| Professional | | $328.34 | $328.34 | $328.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $328.34
| Professional | | $328.34 | $328.34 | $328.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $761.75 / $761.75 / $820.85
| Facility | | $761.75 | $761.75 | $820.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $344.75 / $508.91
| Professional | | $328.34 | $344.75 | $508.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $476.09
| Professional | | $328.34 | $328.34 | $476.09 |