- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $158.49 / $281.84
| Facility | | $158.49 | $158.49 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $239.88 / $316.23
| Professional | | $204.17 | $239.88 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,202.26
| Facility | | $1,096.48 | $1,096.48 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $38.02 / $50.12
| Professional | | $21.38 | $38.02 | $50.12 |