- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $280.50 / $297.33 / $330.00
| Facility | | $280.50 | $297.33 | $330.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.33 / $297.33 / $297.33
| Professional | | $297.33 | $297.33 | $297.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.08 / $190.59 / $371.64
| Facility | | $146.08 | $190.59 | $371.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.88 / $326.48 / $343.59
| Professional | | $274.88 | $326.48 | $343.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.00 / $532.95 / $1,237.50
| Facility | | $330.00 | $532.95 | $1,237.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.25 / $330.28 / $354.30
| Professional | | $300.25 | $330.28 | $354.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.27 / $330.27 / $330.27
| Facility | | $330.27 | $330.27 | $330.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.27 / $330.27 / $330.27
| Professional | | $330.27 | $330.27 | $330.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.25 / $330.28 / $354.30
| Professional | | $300.25 | $330.28 | $354.30 |