- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.26 / $180.26 / $223.36
| Professional | | $180.26 | $180.26 | $223.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.87 / $298.87 / $298.87
| Professional | | $298.87 | $298.87 | $298.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.27 / $211.27 / $211.27
| Facility | | $211.27 | $211.27 | $211.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.22 / $183.54 / $225.22
| Professional | | $154.22 | $183.54 | $225.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.27 / $211.27 / $211.27
| Facility | | $211.27 | $211.27 | $211.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.22 / $183.54 / $225.22
| Professional | | $154.22 | $183.54 | $225.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.78 / $277.61 / $427.05
| Professional | | $127.78 | $277.61 | $427.05 |