- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.38 / $256.93 / $346.22
| Facility | | $86.38 | $256.93 | $346.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.38 / $86.38 / $86.38
| Professional | | $86.38 | $86.38 | $86.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.38 / $214.24 / $362.25
| Professional | | $86.38 | $214.24 | $362.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.48 / $81.48 / $86.38
| Facility | | $81.48 | $81.48 | $86.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.42 / $73.42 / $86.38
| Professional | | $73.42 | $73.42 | $86.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.61 / $86.38 / $140.53
| Professional | | $78.61 | $86.38 | $140.53 |