- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.83 / $311.83 / $389.79
| Professional | | $311.83 | $311.83 | $389.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.72 / $477.72 / $477.72
| Facility | | $477.72 | $477.72 | $477.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.00 / $684.55 / $684.55
| Professional | | $202.00 | $684.55 | $684.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.10 / $260.00 / $273.73
| Facility | | $166.10 | $260.00 | $273.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.10 / $260.00 / $279.56
| Professional | | $166.10 | $260.00 | $279.56 |