- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.60 / $166.60 / $428.40
| Facility | | $166.60 | $166.60 | $428.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.60 / $223.72 / $223.72
| Professional | | $166.60 | $223.72 | $223.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.41 / $273.41 / $401.37
| Professional | | $273.41 | $273.41 | $401.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.80 / $171.36 / $428.40
| Facility | | $142.80 | $171.36 | $428.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.91 / $203.21 / $476.00
| Professional | | $82.91 | $203.21 | $476.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.91 / $203.21 / $404.60
| Professional | | $82.91 | $203.21 | $404.60 |