- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.48 / $170.48 / $287.01
| Professional | | $170.48 | $170.48 | $287.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.99 / $192.99 / $192.99
| Facility | | $192.99 | $192.99 | $192.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.83 / $553.41 / $922.36
| Facility | | $160.83 | $553.41 | $922.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.48 / $170.48 / $170.48
| Professional | | $170.48 | $170.48 | $170.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.83 / $553.41 / $922.36
| Facility | | $160.83 | $553.41 | $922.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.48 / $170.48 / $170.48
| Professional | | $170.48 | $170.48 | $170.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.48 / $170.48 / $262.25
| Professional | | $170.48 | $170.48 | $262.25 |