- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $616.60
| Facility | | $346.74 | $346.74 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $407.38
| Professional | | $346.74 | $346.74 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $436.52 / $1,023.29
| Facility | | $346.74 | $436.52 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $346.74 / $1,071.52
| Professional | | $125.89 | $346.74 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $346.74 / $691.83
| Facility | | $331.13 | $346.74 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $457.09
| Professional | | $346.74 | $346.74 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $524.81 / $977.24
| Facility | | $363.08 | $524.81 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $363.08 / $676.08
| Professional | | $125.89 | $363.08 | $676.08 |