- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.22 / $217.22 / $337.77
| Facility | | $217.22 | $217.22 | $337.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.06 / $210.64 / $217.22
| Professional | | $170.06 | $210.64 | $217.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.73 / $451.76 / $496.96
| Professional | | $375.73 | $451.76 | $496.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.21 / $345.14 / $477.08
| Professional | | $228.21 | $345.14 | $477.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.22 / $256.05 / $458.11
| Facility | | $217.22 | $256.05 | $458.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.70 / $423.34 / $1,301.77
| Professional | | $218.70 | $423.34 | $1,301.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.08 / $401.23 / $484.52
| Professional | | $236.08 | $401.23 | $484.52 |