- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.30 / $132.88 / $132.88
| Facility | | $106.30 | $132.88 | $132.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.88 / $132.88 / $132.88
| Professional | | $132.88 | $132.88 | $132.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.06 / $251.06 / $251.06
| Facility | | $251.06 | $251.06 | $251.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.06 / $251.06 / $251.06
| Professional | | $251.06 | $251.06 | $251.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.80 / $42.37 / $57.66
| Facility | | $24.80 | $42.37 | $57.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $20.00
| Professional | | $17.00 | $20.00 | $20.00 |