- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $483.52 / $483.52 / $483.52
| Facility | | $483.52 | $483.52 | $483.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $255.11 / $272.52
| Professional | | $245.30 | $255.11 | $272.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Professional | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Facility | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Professional | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Professional | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $483.52 / $483.52 / $483.52
| Facility | | $483.52 | $483.52 | $483.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $255.11 / $497.46
| Professional | | $245.30 | $255.11 | $497.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.06 / $245.30 / $355.69
| Professional | | $221.06 | $245.30 | $355.69 |