- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.58 / $292.58 / $292.58
| Facility | | $292.58 | $292.58 | $292.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.58 / $310.62 / $334.39
| Professional | | $292.58 | $310.62 | $334.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $364.44 / $364.44 / $364.44
| Facility | | $364.44 | $364.44 | $364.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.04 / $364.44 / $364.44
| Professional | | $266.04 | $364.44 | $364.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.57 / $409.57 / $2,756.24
| Facility | | $166.57 | $409.57 | $2,756.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.01 / $340.95 / $665.95
| Professional | | $172.01 | $340.95 | $665.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.01 / $307.48 / $388.75
| Professional | | $172.01 | $307.48 | $388.75 |