- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.58 / $254.64 / $3,200.63
| Facility | | $203.58 | $254.64 | $3,200.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $226.18 / $274.83
| Professional | | $203.58 | $226.18 | $274.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.02 / $168.02 / $184.82
| Facility | | $168.02 | $168.02 | $184.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.58 / $203.58 / $218.37
| Facility | | $203.58 | $203.58 | $218.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $203.58 / $203.58
| Professional | | $203.58 | $203.58 | $203.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $207.65 / $282.08
| Professional | | $203.58 | $207.65 | $282.08 |