- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.09 / $217.09 / $262.68
| Professional | | $217.09 | $217.09 | $262.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.76 / $245.76 / $245.76
| Facility | | $245.76 | $245.76 | $245.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.80 / $243.12 / $395.87
| Facility | | $204.80 | $243.12 | $395.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.09 / $217.09 / $395.87
| Professional | | $217.09 | $217.09 | $395.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.80 / $243.12 / $395.87
| Facility | | $204.80 | $243.12 | $395.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.09 / $217.09 / $395.87
| Professional | | $217.09 | $217.09 | $395.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.10 / $230.12 / $501.56
| Professional | | $214.10 | $230.12 | $501.56 |