- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.42 / $307.42 / $307.42
| Facility | | $307.42 | $307.42 | $307.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.42 / $307.42 / $307.42
| Professional | | $307.42 | $307.42 | $307.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.30 / $294.30 / $294.30
| Professional | | $294.30 | $294.30 | $294.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.48 / $88.10 / $100.68
| Facility | | $81.48 | $88.10 | $100.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.00 / $296.00 / $317.49
| Professional | | $254.00 | $296.00 | $317.49 |