- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.38 / $781.38 / $1,202.51
| Facility | | $175.38 | $781.38 | $1,202.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.10 / $238.46 / $247.99
| Professional | | $210.10 | $238.46 | $247.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.46 / $476.92 / $577.07
| Facility | | $238.46 | $476.92 | $577.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.46 / $238.46 / $329.07
| Professional | | $238.46 | $238.46 | $329.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.46 / $238.46 / $357.69
| Facility | | $238.46 | $238.46 | $357.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.46 / $238.46 / $298.08
| Professional | | $238.46 | $238.46 | $298.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.46 / $238.46 / $331.92
| Facility | | $238.46 | $238.46 | $331.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.46 / $238.46 / $398.30
| Professional | | $238.46 | $238.46 | $398.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.46 / $265.45 / $321.92
| Professional | | $238.46 | $265.45 | $321.92 |