- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.72 / $308.72 / $540.26
| Facility | | $308.72 | $308.72 | $540.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.72 / $308.72 / $569.27
| Professional | | $308.72 | $308.72 | $569.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.13 / $397.13 / $397.13
| Professional | | $397.13 | $397.13 | $397.13 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.48 / $837.48 / $837.48
| Professional | | $837.48 | $837.48 | $837.48 |