- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.18 / $206.18 / $206.18
| Facility | | $206.18 | $206.18 | $206.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.74 / $206.18 / $324.87
| Professional | | $139.74 | $206.18 | $324.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $178.86 / $178.86 / $178.86
| Facility | | $178.86 | $178.86 | $178.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.14 / $152.03 / $178.86
| Professional | | $20.14 | $152.03 | $178.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.82 / $164.28 / $324.87
| Facility | | $27.82 | $164.28 | $324.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.01 / $26.19 / $251.14
| Professional | | $17.01 | $26.19 | $251.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.44 / $140.91 / $354.35
| Professional | | $110.44 | $140.91 | $354.35 |