- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.25 / $253.63 / $253.63
| Professional | | $204.25 | $253.63 | $253.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.78 / $212.44 / $321.26
| Professional | | $175.78 | $212.44 | $321.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.20 / $253.63 / $356.99
| Professional | | $213.20 | $253.63 | $356.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.19 / $202.80 / $315.56
| Professional | | $182.19 | $202.80 | $315.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.25 / $253.63 / $253.63
| Professional | | $204.25 | $253.63 | $253.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.19 / $257.08 / $320.73
| Professional | | $182.19 | $257.08 | $320.73 |