- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $438.88
| Facility | | $243.71 | $243.71 | $438.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $334.68
| Professional | | $243.71 | $243.71 | $334.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $264.39 / $265.72 / $269.13
| Facility | | $264.39 | $265.72 | $269.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.53 / $265.72 / $269.13
| Professional | | $225.53 | $265.72 | $269.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.00 / $292.00 / $335.80
| Facility | | $292.00 | $292.00 | $335.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.71 / $247.10 / $310.70
| Professional | | $243.71 | $247.10 | $310.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.82 / $268.20 / $438.68
| Facility | | $243.82 | $268.20 | $438.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.82 / $271.42 / $1,059.88
| Professional | | $243.82 | $271.42 | $1,059.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $303.86
| Professional | | $243.71 | $243.71 | $303.86 |