- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $769.02 / $769.02 / $769.02
| Facility | | $769.02 | $769.02 | $769.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $248.45
| Professional | | $236.62 | $236.62 | $248.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.10 / $236.62 / $250.01
| Facility | | $231.10 | $236.62 | $250.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $236.62
| Professional | | $236.62 | $236.62 | $236.62 |
- 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 / $236.62
| Professional | | $236.62 | $236.62 | $236.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $263.41
| Professional | | $236.62 | $236.62 | $263.41 |