- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.61 / $291.77 / $503.32
| Facility | | $243.61 | $291.77 | $503.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.61 / $244.59 / $293.26
| Professional | | $243.61 | $244.59 | $293.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.61 / $354.62 / $772.00
| Facility | | $243.61 | $354.62 | $772.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.61 / $243.61 / $243.61
| Professional | | $243.61 | $243.61 | $243.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.82 / $243.61 / $243.61
| Facility | | $229.82 | $243.61 | $243.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.61 / $243.61 / $243.61
| Professional | | $243.61 | $243.61 | $243.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.35 / $243.61 / $258.23
| Professional | | $158.35 | $243.61 | $258.23 |