- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.27 / $131.27 / $131.27
| Facility | | $131.27 | $131.27 | $131.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.27 / $155.44 / $207.11
| Professional | | $131.27 | $155.44 | $207.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.71 / $180.71 / $385.60
| Facility | | $180.71 | $180.71 | $385.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.91 / $131.91 / $337.64
| Professional | | $131.91 | $131.91 | $337.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.28 / $354.75 / $505.14
| Professional | | $352.28 | $354.75 | $505.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.64 / $376.56 / $385.60
| Professional | | $337.64 | $376.56 | $385.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.28 / $192.37 / $301.80
| Professional | | $144.28 | $192.37 | $301.80 |