- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.62 / $172.62 / $238.38
| Facility | | $172.62 | $172.62 | $238.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.20 / $132.88 / $172.62
| Professional | | $82.20 | $132.88 | $172.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.30 / $205.50 / $205.50
| Professional | | $123.30 | $205.50 | $205.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.05 / $176.92 / $256.75
| Facility | | $89.05 | $176.92 | $256.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.92 / $120.82 / $206.16
| Professional | | $55.92 | $120.82 | $206.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $82.20 / $137.00
| Professional | | $57.54 | $82.20 | $137.00 |