- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $343.22 / $343.22 / $343.22
| Facility | | $343.22 | $343.22 | $343.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.47 / $223.36 / $343.22
| Professional | | $162.47 | $223.36 | $343.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.40 / $224.40 / $224.40
| Professional | | $224.40 | $224.40 | $224.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.27 / $211.27 / $378.49
| Facility | | $211.27 | $211.27 | $378.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.22 / $211.27 / $331.42
| Professional | | $154.22 | $211.27 | $331.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.45 / $168.68 / $261.36
| Professional | | $112.45 | $168.68 | $261.36 |