- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.02 / $285.02 / $285.02
| Facility | | $285.02 | $285.02 | $285.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.16 / $285.02 / $285.02
| Professional | | $244.16 | $285.02 | $285.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.77 / $281.77 / $306.89
| Professional | | $281.77 | $281.77 | $306.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.02 / $285.02 / $285.02
| Facility | | $285.02 | $285.02 | $285.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.36 / $285.02 / $285.02
| Professional | | $251.36 | $285.02 | $285.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.97 / $1,018.45 / $1,018.45
| Professional | | $678.97 | $1,018.45 | $1,018.45 |