- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.94 / $102.94 / $174.36
| Professional | | $102.94 | $102.94 | $174.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.53 / $116.53 / $116.53
| Facility | | $116.53 | $116.53 | $116.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.11 / $125.30 / $208.83
| Facility | | $97.11 | $125.30 | $208.83 |
- 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 / $125.30 / $208.83
| Facility | | $97.11 | $125.30 | $208.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.94 / $102.94 / $102.94
| Professional | | $102.94 | $102.94 | $102.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.79 / $102.94 / $158.35
| Professional | | $97.79 | $102.94 | $158.35 |