- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.38 / $182.38 / $182.38
| Facility | | $182.38 | $182.38 | $182.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.76 / $182.54 / $205.37
| Professional | | $137.76 | $182.54 | $205.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.71 / $32.81 / $46.59
| Professional | | $27.71 | $32.81 | $46.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.45 / $41.43 / $77.51
| Professional | | $34.45 | $41.43 | $77.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.53 / $318.50 / $318.50
| Facility | | $120.53 | $318.50 | $318.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.60 / $187.43 / $279.63
| Professional | | $137.60 | $187.43 | $279.63 |