- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $236.62
| Facility | | $236.62 | $236.62 | $236.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $352.56
| Professional | | $236.62 | $236.62 | $352.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.61 / $236.61 / $236.61
| Professional | | $236.61 | $236.61 | $236.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.12 / $233.12 / $233.12
| Facility | | $233.12 | $233.12 | $233.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $279.02
| Professional | | $236.62 | $236.62 | $279.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.13 / $236.62 / $248.45
| Professional | | $201.13 | $236.62 | $248.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $263.41 / $286.31
| Professional | | $236.62 | $263.41 | $286.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.12 / $233.12 / $319.44
| Professional | | $233.12 | $233.12 | $319.44 |