- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $261.08 / $261.08 / $924.47
| Facility | | $261.08 | $261.08 | $924.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.07 / $261.08 / $265.91
| Professional | | $261.07 | $261.08 | $265.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.58 / $265.58 / $265.58
| Facility | | $265.58 | $265.58 | $265.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.58 / $265.58 / $265.58
| Professional | | $265.58 | $265.58 | $265.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.75 / $270.18 / $1,006.31
| Facility | | $198.75 | $270.18 | $1,006.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.27 / $279.81 / $284.56
| Professional | | $225.27 | $279.81 | $284.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.27 / $279.81 / $284.56
| Professional | | $225.27 | $279.81 | $284.56 |