- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $223.87
| Facility | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $208.93 / $309.03
| Professional | | $169.82 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $213.80 / $380.19
| Professional | | $158.49 | $213.80 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $234.42 / $407.38
| Professional | | $141.25 | $234.42 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $218.78 / $389.05
| Professional | | $204.17 | $218.78 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $208.93 / $346.74
| Professional | | $141.25 | $208.93 | $346.74 |