- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.41 / $152.41 / $152.41
| Facility | | $152.41 | $152.41 | $152.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.51 / $152.41 / $152.41
| Professional | | $126.51 | $152.41 | $152.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.26 / $141.26 / $153.66
| Professional | | $141.26 | $141.26 | $153.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.41 / $152.41 / $152.41
| Facility | | $152.41 | $152.41 | $152.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.52 / $152.41 / $152.41
| Professional | | $130.52 | $152.41 | $152.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $382.66 / $382.66
| Professional | | $30.00 | $382.66 | $382.66 |