- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.52 / $336.08 / $563.32
| Facility | | $258.52 | $336.08 | $563.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.52 / $258.64 / $312.81
| Professional | | $258.52 | $258.64 | $312.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.93 / $248.93 / $258.52
| Professional | | $248.93 | $248.93 | $258.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.93 / $270.07 / $309.73
| Professional | | $248.93 | $270.07 | $309.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.93 / $258.64 / $258.64
| Facility | | $248.93 | $258.64 | $258.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.64 / $258.64 / $258.64
| Professional | | $258.64 | $258.64 | $258.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.12 / $344.04 / $1,293.20
| Facility | | $331.12 | $344.04 | $1,293.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,942.60 / $6,942.60 / $6,942.60
| Professional | | $6,942.60 | $6,942.60 | $6,942.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.71 / $258.64 / $289.01
| Professional | | $245.71 | $258.64 | $289.01 |