- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.80 / $271.57 / $356.69
| Facility | | $159.80 | $271.57 | $356.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.50 / $257.99 / $360.00
| Professional | | $212.50 | $257.99 | $360.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.99 / $438.58 / $926.70
| Facility | | $257.99 | $438.58 | $926.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.57 / $271.57 / $271.57
| Professional | | $260.57 | $271.57 | $271.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.60 / $253.60 / $253.60
| Facility | | $253.60 | $253.60 | $253.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.60 / $253.60 / $253.60
| Professional | | $253.60 | $253.60 | $253.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.23 / $279.89 / $1,018.39
| Facility | | $248.23 | $279.89 | $1,018.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.99 / $275.52 / $312.01
| Professional | | $257.99 | $275.52 | $312.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.99 / $275.52 / $312.01
| Professional | | $257.99 | $275.52 | $312.01 |