- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $343.28 / $343.28 / $343.28
| Facility | | $343.28 | $343.28 | $343.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.34 / $343.28 / $343.28
| Professional | | $174.34 | $343.28 | $343.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.94 / $303.94 / $303.94
| Professional | | $303.94 | $303.94 | $303.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $299.52 / $299.52 / $463.00
| Facility | | $299.52 | $299.52 | $463.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.65 / $299.52 / $405.42
| Professional | | $218.65 | $299.52 | $405.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $462.82 / $462.82 / $544.49
| Facility | | $462.82 | $462.82 | $544.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.82 / $203.73 / $313.94
| Professional | | $135.82 | $203.73 | $313.94 |