- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.66 / $107.66 / $107.66
| Facility | | $107.66 | $107.66 | $107.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.33 / $107.66 / $130.72
| Professional | | $86.33 | $107.66 | $130.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.55 / $204.49 / $240.58
| Professional | | $176.55 | $204.49 | $240.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.00 / $115.14 / $144.78
| Professional | | $114.00 | $115.14 | $144.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.41 / $107.66 / $147.62
| Facility | | $98.41 | $107.66 | $147.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.07 / $202.18 / $661.36
| Professional | | $110.07 | $202.18 | $661.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.07 / $194.82 / $268.07
| Professional | | $110.07 | $194.82 | $268.07 |