- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.66 / $174.15 / $195.24
| Facility | | $91.66 | $174.15 | $195.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.66 / $91.66 / $120.06
| Professional | | $91.66 | $91.66 | $120.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.66 / $239.15 / $373.32
| Professional | | $210.66 | $239.15 | $373.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.05 / $0.09 / $200.00
| Professional | | $0.05 | $0.09 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.09 / $0.09 / $0.09
| Professional | | $0.09 | $0.09 | $0.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $51.00
| Professional | | $30.00 | $30.00 | $51.00 |