- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.94 / $155.38 / $155.49
| Facility | | $135.94 | $155.38 | $155.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $135.94 / $174.80
| Professional | | $129.47 | $135.94 | $174.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.63 / $123.63 / $124.00
| Facility | | $123.63 | $123.63 | $124.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $154.41
| Facility | | $129.47 | $129.47 | $154.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $129.47
| Professional | | $129.47 | $129.47 | $129.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.30 / $129.47 / $165.73
| Professional | | $124.30 | $129.47 | $165.73 |