- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.28 / $114.28 / $114.28
| Facility | | $114.28 | $114.28 | $114.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.59 / $114.28 / $118.79
| Professional | | $99.59 | $114.28 | $118.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $141.06
| Professional | | $141.06 | $141.06 | $141.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.54 / $130.04 / $361.86
| Professional | | $103.54 | $130.04 | $361.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.37 / $163.94 / $381.98
| Professional | | $82.37 | $163.94 | $381.98 |