- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.26 / $164.26 / $236.81
| Professional | | $164.26 | $164.26 | $236.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.51 / $198.51 / $198.51
| Professional | | $198.51 | $198.51 | $198.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.81 / $243.91 / $1,372.22
| Facility | | $236.81 | $243.91 | $1,372.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.00 / $209.81 / $214.58
| Professional | | $115.00 | $209.81 | $214.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.00 / $212.09 / $214.58
| Professional | | $115.00 | $212.09 | $214.58 |