- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.78 / $161.61 / $902.38
| Professional | | $153.78 | $161.61 | $902.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.74 / $269.74 / $269.74
| Facility | | $269.74 | $269.74 | $269.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.52 / $269.74 / $277.61
| Professional | | $140.52 | $269.74 | $277.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.18 / $183.12 / $269.74
| Facility | | $133.18 | $183.12 | $269.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.99 / $269.74 / $357.00
| Professional | | $164.99 | $269.74 | $357.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.35 / $283.29 / $328.02
| Professional | | $237.35 | $283.29 | $328.02 |