- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $343.42
| Facility | | $245.30 | $245.30 | $343.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $272.52
| Professional | | $245.30 | $245.30 | $272.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.52 / $248.45 / $473.43
| Facility | | $243.52 | $248.45 | $473.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $276.20
| Professional | | $245.30 | $245.30 | $276.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.65 / $245.30 / $245.30
| Facility | | $233.65 | $245.30 | $245.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $266.13
| Professional | | $245.30 | $245.30 | $266.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $282.10
| Professional | | $245.30 | $245.30 | $282.10 |