- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.72 / $308.72 / $333.97
| Facility | | $308.72 | $308.72 | $333.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.72 / $308.72 / $569.27
| Professional | | $308.72 | $308.72 | $569.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $357.00 / $666.92 / $1,073.64
| Facility | | $357.00 | $666.92 | $1,073.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $33.00
| Professional | | $30.00 | $30.00 | $33.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.52 / $515.52 / $515.52
| Facility | | $515.52 | $515.52 | $515.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.84 / $604.84 / $604.84
| Professional | | $604.84 | $604.84 | $604.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.85 / $636.29 / $636.29
| Professional | | $540.85 | $636.29 | $636.29 |