- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.11 / $512.11 / $512.11
| Facility | | $512.11 | $512.11 | $512.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.42 / $318.20 / $512.11
| Professional | | $242.42 | $318.20 | $512.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.32 / $407.32 / $407.32
| Professional | | $407.32 | $407.32 | $407.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.25 / $315.25 / $564.79
| Facility | | $315.25 | $315.25 | $564.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.13 / $315.25 / $494.55
| Professional | | $230.13 | $315.25 | $494.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.80 / $251.69 / $389.97
| Professional | | $167.80 | $251.69 | $389.97 |