- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.71 / $524.71 / $524.71
| Facility | | $524.71 | $524.71 | $524.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.38 / $524.71 / $524.71
| Professional | | $248.38 | $524.71 | $524.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $419.16 / $419.16 / $419.16
| Professional | | $419.16 | $419.16 | $419.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $378.92 / $378.92 / $743.62
| Facility | | $378.92 | $378.92 | $743.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.61 / $378.92 / $651.14
| Professional | | $276.61 | $378.92 | $651.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.50 / $290.24 / $437.21
| Professional | | $193.50 | $290.24 | $437.21 |