- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.15 / $382.23 / $545.72
| Facility | | $230.15 | $382.23 | $545.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $253.17
| Professional | | $230.15 | $230.15 | $253.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.13 / $230.15 / $234.70
| Facility | | $217.13 | $230.15 | $234.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $230.15
| Professional | | $230.15 | $230.15 | $230.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.29 / $230.15 / $230.15
| Facility | | $132.29 | $230.15 | $230.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $230.15
| Professional | | $230.15 | $230.15 | $230.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $268.01
| Professional | | $230.15 | $230.15 | $268.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.26 / $230.26
| Professional | | $230.15 | $230.26 | $230.26 |