- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.06 / $127.06 / $127.06
| Facility | | $127.06 | $127.06 | $127.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.65 / $120.01 / $127.06
| Professional | | $92.65 | $120.01 | $127.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.28 / $193.05 / $197.85
| Professional | | $163.28 | $193.05 | $197.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.25 / $202.25 / $254.32
| Professional | | $200.25 | $202.25 | $254.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.58 / $127.06 / $804.26
| Facility | | $80.58 | $127.06 | $804.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.56 / $85.46 / $139.13
| Professional | | $69.56 | $85.46 | $139.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.27 / $85.46 / $183.12
| Professional | | $60.27 | $85.46 | $183.12 |