- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.43 / $327.43 / $327.43
| Facility | | $327.43 | $327.43 | $327.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.43 / $327.43 / $390.48
| Professional | | $327.43 | $327.43 | $390.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.31 / $310.31 / $310.31
| Professional | | $310.31 | $310.31 | $310.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.71 / $195.71 / $228.19
| Facility | | $195.71 | $195.71 | $228.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.43 / $327.43 / $327.43
| Facility | | $327.43 | $327.43 | $327.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.31 / $327.43 / $389.64
| Professional | | $286.31 | $327.43 | $389.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.31 / $310.31 / $310.31
| Professional | | $310.31 | $310.31 | $310.31 |