- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $272.52
| Professional | | $245.30 | $245.30 | $272.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.42 / $279.64 / $466.07
| Facility | | $231.42 | $279.64 | $466.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $466.07
| Professional | | $245.30 | $245.30 | $466.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.42 / $279.64 / $466.07
| Facility | | $231.42 | $279.64 | $466.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $466.07
| Professional | | $245.30 | $245.30 | $466.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.06 / $245.30 / $735.90
| Professional | | $221.06 | $245.30 | $735.90 |