- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.57 / $257.57 / $294.36
| Facility | | $257.57 | $257.57 | $294.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $257.57 / $294.36
| Professional | | $245.30 | $257.57 | $294.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.04 / $266.04 / $266.04
| Professional | | $266.04 | $266.04 | $266.04 |
- 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
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.04 / $245.30 / $318.89
| Professional | | $233.04 | $245.30 | $318.89 |