- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.12 / $306.12 / $306.12
| Facility | | $306.12 | $306.12 | $306.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.08 / $260.20 / $306.12
| Professional | | $254.08 | $260.20 | $306.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.00 / $321.00 / $401.25
| Professional | | $321.00 | $321.00 | $401.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.08 / $393.98 / $754.90
| Facility | | $43.08 | $393.98 | $754.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.10 / $255.10 / $290.81
| Professional | | $255.10 | $255.10 | $290.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.42 / $261.02 / $615.80
| Facility | | $103.42 | $261.02 | $615.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.42 / $261.02 / $571.02
| Professional | | $103.42 | $261.02 | $571.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.20 / $260.20 / $260.20
| Professional | | $260.20 | $260.20 | $260.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.10 / $255.10 / $280.61
| Professional | | $255.10 | $255.10 | $280.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.10 / $255.10 / $255.10
| Professional | | $255.10 | $255.10 | $255.10 |