- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.43 / $235.86 / $280.08
| Facility | | $164.43 | $235.86 | $280.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.66 / $219.82 / $280.62
| Professional | | $218.66 | $219.82 | $280.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.00 / $63.00 / $63.00
| Professional | | $63.00 | $63.00 | $63.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.37 / $241.37 / $241.37
| Facility | | $241.37 | $241.37 | $241.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.37 / $241.37 / $241.37
| Professional | | $241.37 | $241.37 | $241.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.68 / $517.22 / $890.51
| Facility | | $245.68 | $517.22 | $890.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.51 / $215.51 / $258.61
| Professional | | $215.51 | $215.51 | $258.61 |