- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.92 / $107.92 / $107.92
| Facility | | $107.92 | $107.92 | $107.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.56 / $32.81 / $225.63
| Professional | | $24.56 | $32.81 | $225.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.91 / $155.41 / $190.01
| Facility | | $148.91 | $155.41 | $190.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.74 / $58.74 / $200.10
| Facility | | $58.74 | $58.74 | $200.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.74 / $58.74 / $200.10
| Facility | | $58.74 | $58.74 | $200.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.81 / $22.81 / $22.81
| Professional | | $22.81 | $22.81 | $22.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.33 / $49.00 / $157.91
| Professional | | $15.33 | $49.00 | $157.91 |