- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.06 / $308.06 / $308.06
| Facility | | $308.06 | $308.06 | $308.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.83 / $308.06 / $308.06
| Professional | | $145.83 | $308.06 | $308.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.23 / $254.23 / $254.23
| Professional | | $254.23 | $254.23 | $254.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.09 / $205.09 / $317.05
| Facility | | $205.09 | $205.09 | $317.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.72 / $205.09 / $277.62
| Professional | | $149.72 | $205.09 | $277.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.45 / $158.16 / $252.57
| Professional | | $105.45 | $158.16 | $252.57 |