- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.78 / $239.78 / $239.78
| Facility | | $239.78 | $239.78 | $239.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.62 / $197.62 / $239.78
| Professional | | $197.62 | $197.62 | $239.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.67 / $367.06 / $373.41
| Professional | | $313.67 | $367.06 | $373.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.13 / $385.95 / $485.30
| Professional | | $382.13 | $385.95 | $485.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.70 / $239.78 / $1,682.37
| Facility | | $188.70 | $239.78 | $1,682.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.30 / $191.82 / $274.02
| Professional | | $131.30 | $191.82 | $274.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.61 / $191.82 / $391.14
| Professional | | $109.61 | $191.82 | $391.14 |