- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.58 / $111.58 / $111.58
| Facility | | $111.58 | $111.58 | $111.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.58 / $118.86 / $118.86
| Professional | | $111.58 | $118.86 | $118.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.75 / $404.21 / $496.55
| Facility | | $138.75 | $404.21 | $496.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.36 / $268.92 / $1,298.23
| Professional | | $149.36 | $268.92 | $1,298.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.08 / $172.22 / $470.40
| Professional | | $100.08 | $172.22 | $470.40 |