- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.87 / $241.87 / $241.87
| Facility | | $241.87 | $241.87 | $241.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.81 / $241.87 / $241.87
| Professional | | $236.81 | $241.87 | $241.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.04 / $339.04 / $339.04
| Professional | | $339.04 | $339.04 | $339.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.64 / $400.21 / $648.86
| Facility | | $338.64 | $400.21 | $648.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.01 / $513.08 / $1,846.48
| Professional | | $302.01 | $513.08 | $1,846.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $284.67 / $372.84 / $431.73
| Facility | | $284.67 | $372.84 | $431.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.04 / $372.84 / $457.18
| Professional | | $339.04 | $372.84 | $457.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.19 / $530.57 / $720.36
| Professional | | $245.19 | $530.57 | $720.36 |