- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.94 / $127.88 / $227.54
| Facility | | $102.94 | $127.88 | $227.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.94 / $103.74 / $122.80
| Professional | | $102.94 | $103.74 | $122.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.23 / $171.28 / $327.28
| Facility | | $104.23 | $171.28 | $327.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.94 / $102.94 / $102.94
| Professional | | $102.94 | $102.94 | $102.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.11 / $102.94 / $102.94
| Facility | | $97.11 | $102.94 | $102.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.94 / $102.94 / $102.94
| Professional | | $102.94 | $102.94 | $102.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.93 / $102.93 / $102.93
| Facility | | $102.93 | $102.93 | $102.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.94 / $102.94 / $129.19
| Professional | | $102.94 | $102.94 | $129.19 |