- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.94 / $161.94 / $253.23
| Professional | | $161.94 | $161.94 | $253.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $282.42 / $282.42 / $282.42
| Facility | | $282.42 | $282.42 | $282.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.42 / $282.42 / $282.42
| Professional | | $282.42 | $282.42 | $282.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.71 / $180.71 / $424.16
| Facility | | $180.71 | $180.71 | $424.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.91 / $131.91 / $180.71
| Professional | | $131.91 | $131.91 | $180.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.40 / $144.28 / $220.79
| Professional | | $130.40 | $144.28 | $220.79 |