- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $489.78
| Facility | | $371.54 | $371.54 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $52.48 / $741.31
| Professional | | $30.20 | $52.48 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $208.93 / $223.87
| Professional | | $186.21 | $208.93 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $363.08 / $467.74
| Professional | | $269.15 | $363.08 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $107.15
| Professional | | $107.15 | $107.15 | $107.15 |