- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.50 / $248.50 / $534.16
| Professional | | $248.50 | $248.50 | $534.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.32 / $281.32 / $281.32
| Facility | | $281.32 | $281.32 | $281.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.43 / $275.80 / $459.67
| Facility | | $234.43 | $275.80 | $459.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.50 / $248.50 / $459.67
| Professional | | $248.50 | $248.50 | $459.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.43 / $275.80 / $459.67
| Facility | | $234.43 | $275.80 | $459.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.50 / $248.50 / $459.67
| Professional | | $248.50 | $248.50 | $459.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.90 / $263.41 / $575.10
| Professional | | $243.90 | $263.41 | $575.10 |