- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $414.76 / $414.76 / $414.76
| Facility | | $414.76 | $414.76 | $414.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.33 / $414.76 / $414.76
| Professional | | $196.33 | $414.76 | $414.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.28 / $342.28 / $342.28
| Professional | | $342.28 | $342.28 | $342.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $352.55 / $352.55 / $500.28
| Facility | | $352.55 | $352.55 | $500.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.36 / $352.55 / $438.06
| Professional | | $257.36 | $352.55 | $438.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.94 / $229.42 / $345.60
| Professional | | $152.94 | $229.42 | $345.60 |