- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.52 / $146.52 / $146.52
| Facility | | $146.52 | $146.52 | $146.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.59 / $110.84 / $183.23
| Professional | | $87.59 | $110.84 | $183.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.82 / $138.35 / $201.98
| Professional | | $103.82 | $138.35 | $201.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.84 / $156.11 / $268.75
| Professional | | $118.84 | $156.11 | $268.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.66 / $171.82 / $234.64
| Professional | | $132.66 | $171.82 | $234.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.66 / $157.56 / $460.99
| Professional | | $153.66 | $157.56 | $460.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.51 / $147.65 / $223.04
| Professional | | $106.51 | $147.65 | $223.04 |