- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.73 / $210.73 / $210.73
| Facility | | $210.73 | $210.73 | $210.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.14 / $210.73 / $274.35
| Professional | | $197.14 | $210.73 | $274.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.71 / $301.89 / $370.72
| Professional | | $222.71 | $301.89 | $370.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.16 / $370.72 / $370.72
| Professional | | $364.16 | $370.72 | $370.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.73 / $511.29 / $679.85
| Professional | | $268.73 | $511.29 | $679.85 |