- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.66 / $210.66 / $210.66
| Facility | | $210.66 | $210.66 | $210.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.66 / $210.66 / $210.66
| Professional | | $210.66 | $210.66 | $210.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.65 / $221.48 / $270.17
| Professional | | $220.65 | $221.48 | $270.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.57 / $194.57 / $194.57
| Professional | | $194.57 | $194.57 | $194.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.89 / $256.89 / $784.54
| Professional | | $256.89 | $256.89 | $784.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.44 / $197.17 / $337.00
| Professional | | $131.44 | $197.17 | $337.00 |