- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $738.66 / $738.66 / $738.66
| Facility | | $738.66 | $738.66 | $738.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.28 / $227.28 / $236.37
| Professional | | $227.28 | $227.28 | $236.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.10 / $227.10 / $247.76
| Facility | | $227.10 | $227.10 | $247.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.28 / $227.28 / $227.28
| Professional | | $227.28 | $227.28 | $227.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.28 / $227.28 / $227.28
| Facility | | $227.28 | $227.28 | $227.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.28 / $227.28 / $227.28
| Professional | | $227.28 | $227.28 | $227.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.28 / $227.28 / $227.28
| Facility | | $227.28 | $227.28 | $227.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.28 / $227.28 / $253.01
| Professional | | $227.28 | $227.28 | $253.01 |