- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.37 / $141.37 / $141.37
| Facility | | $141.37 | $141.37 | $141.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.77 / $147.66 / $162.36
| Professional | | $131.77 | $147.66 | $162.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.27 / $331.06 / $346.31
| Professional | | $268.27 | $331.06 | $346.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.44 / $275.68 / $425.49
| Professional | | $180.44 | $275.68 | $425.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.16 / $147.66 / $327.22
| Facility | | $120.16 | $147.66 | $327.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.06 / $251.55 / $871.74
| Professional | | $144.06 | $251.55 | $871.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.32 / $238.84 / $334.65
| Professional | | $141.32 | $238.84 | $334.65 |