- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.60 / $100.60 / $820.88
| Facility | | $100.60 | $100.60 | $820.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.60 / $100.60 / $104.62
| Professional | | $100.60 | $100.60 | $104.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.30 / $107.30 / $107.30
| Professional | | $107.30 | $107.30 | $107.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.95 / $226.67 / $488.05
| Facility | | $217.95 | $226.67 | $488.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.01 / $156.01 / $171.45
| Professional | | $156.01 | $156.01 | $171.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.25 / $272.64 / $272.64
| Professional | | $154.25 | $272.64 | $272.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.33 / $80.48 / $213.27
| Professional | | $56.33 | $80.48 | $213.27 |