- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.11 / $393.53 / $700.43
| Facility | | $255.11 | $393.53 | $700.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $247.76 / $257.57
| Professional | | $245.30 | $247.76 | $257.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Professional | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Facility | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Professional | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.57 / $245.30 / $363.91
| Professional | | $204.57 | $245.30 | $363.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.04 / $245.30 / $260.02
| Professional | | $233.04 | $245.30 | $260.02 |