- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $538.10
| Professional | | $236.62 | $236.62 | $538.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.87 / $267.87 / $267.87
| Facility | | $267.87 | $267.87 | $267.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.22 / $263.91 / $439.85
| Facility | | $223.22 | $263.91 | $439.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $439.85
| Professional | | $236.62 | $236.62 | $439.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.22 / $263.91 / $439.85
| Facility | | $223.22 | $263.91 | $439.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $439.85
| Professional | | $236.62 | $236.62 | $439.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.87 / $250.82 / $547.61
| Professional | | $230.87 | $250.82 | $547.61 |