- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.97 / $240.97 / $240.97
| Facility | | $240.97 | $240.97 | $240.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.80 / $240.97 / $400.92
| Professional | | $236.80 | $240.97 | $400.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.00 / $397.14 / $570.98
| Professional | | $315.00 | $397.14 | $570.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.90 / $393.88 / $434.89
| Facility | | $239.90 | $393.88 | $434.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.52 / $287.52 / $419.51
| Professional | | $287.52 | $287.52 | $419.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.70 / $386.00 / $845.97
| Facility | | $239.70 | $386.00 | $845.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.00 / $303.00 / $325.00
| Professional | | $303.00 | $303.00 | $325.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.98 / $363.98 / $363.98
| Professional | | $363.98 | $363.98 | $363.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.42 / $268.73 / $404.90
| Professional | | $210.42 | $268.73 | $404.90 |