- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $395.59
| Professional | | $230.15 | $230.15 | $395.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.55 / $260.55 / $260.55
| Facility | | $260.55 | $260.55 | $260.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.13 / $252.27 / $420.45
| Facility | | $217.13 | $252.27 | $420.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $230.15
| Professional | | $230.15 | $230.15 | $230.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.13 / $252.27 / $420.45
| Facility | | $217.13 | $252.27 | $420.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $230.15
| Professional | | $230.15 | $230.15 | $230.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.64 / $230.15 / $239.36
| Professional | | $218.64 | $230.15 | $239.36 |