- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $88.53 / $88.53 / $88.53
| Facility | | $88.53 | $88.53 | $88.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.53 / $92.03 / $99.77
| Professional | | $88.53 | $92.03 | $99.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.23 / $78.23 / $78.23
| Professional | | $78.23 | $78.23 | $78.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.63 / $114.35 / $114.35
| Facility | | $100.63 | $114.35 | $114.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.42 / $97.42 / $97.42
| Facility | | $97.42 | $97.42 | $97.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.16 / $109.16 / $109.16
| Facility | | $109.16 | $109.16 | $109.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.90 / $86.90 / $86.90
| Professional | | $86.90 | $86.90 | $86.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.98 / $94.79 / $149.60
| Professional | | $71.98 | $94.79 | $149.60 |