- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.01 / $316.01 / $316.01
| Professional | | $316.01 | $316.01 | $316.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.14 / $287.14 / $316.01
| Facility | | $287.14 | $287.14 | $316.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.61 / $316.01 / $316.01
| Professional | | $268.61 | $316.01 | $316.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.80 / $193.58 / $369.20
| Facility | | $140.80 | $193.58 | $369.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.82 / $316.01 / $396.90
| Professional | | $220.82 | $316.01 | $396.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.04 / $351.12 / $397.39
| Professional | | $326.04 | $351.12 | $397.39 |