- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.71 / $248.71 / $435.24
| Facility | | $248.71 | $248.71 | $435.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.71 / $248.71 / $287.08
| Professional | | $248.71 | $248.71 | $287.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.74 / $653.74 / $653.74
| Professional | | $653.74 | $653.74 | $653.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $404.08 / $404.08 / $404.08
| Facility | | $404.08 | $404.08 | $404.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.56 / $324.56 / $324.56
| Professional | | $324.56 | $324.56 | $324.56 |
- 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
- $449.39 / $449.39 / $449.39
| Professional | | $449.39 | $449.39 | $449.39 |