- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.83 / $939.38 / $939.38
| Professional | | $205.83 | $939.38 | $939.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.83 / $281.83 / $281.83
| Facility | | $281.83 | $281.83 | $281.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.50 / $281.83 / $281.83
| Professional | | $253.50 | $281.83 | $281.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.83 / $281.83 / $281.83
| Facility | | $281.83 | $281.83 | $281.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.01 / $253.50 / $378.70
| Professional | | $175.01 | $253.50 | $378.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.72 / $321.60 / $496.71
| Professional | | $278.72 | $321.60 | $496.71 |