- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.36 / $166.82 / $168.82
| Facility | | $115.36 | $166.82 | $168.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.36 / $119.58 / $168.82
| Professional | | $115.36 | $119.58 | $168.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.40 / $86.40 / $95.04
| Facility | | $86.40 | $86.40 | $95.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.08 / $119.58 / $119.58
| Facility | | $113.08 | $119.58 | $119.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.58 / $119.58 / $119.58
| Professional | | $119.58 | $119.58 | $119.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $17.00 / $20.00
| Professional | | $17.00 | $17.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.55 / $117.24 / $150.07
| Professional | | $112.55 | $117.24 | $150.07 |