- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $230.26
| Facility | | $230.15 | $230.15 | $230.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $232.46 / $241.66
| Professional | | $230.15 | $232.46 | $241.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.87 / $532.92 / $15,593.59
| Facility | | $227.87 | $532.92 | $15,593.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.73 / $230.15 / $230.15
| Professional | | $226.73 | $230.15 | $230.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $230.15
| Facility | | $230.15 | $230.15 | $230.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $318.77
| Professional | | $230.15 | $230.15 | $318.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $230.15
| Professional | | $230.15 | $230.15 | $230.15 |