- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.17 / $266.79 / $373.11
| Professional | | $212.17 | $266.79 | $373.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $532.44 / $532.44 / $532.44
| Facility | | $532.44 | $532.44 | $532.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.53 / $657.30 / $657.30
| Professional | | $623.53 | $657.30 | $657.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.33 / $198.86 / $222.00
| Facility | | $158.33 | $198.86 | $222.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.22 / $198.86 / $266.72
| Professional | | $133.22 | $198.86 | $266.72 |