- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.44 / $136.44 / $157.44
| Professional | | $136.44 | $136.44 | $157.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.66 / $139.66 / $205.51
| Facility | | $139.66 | $139.66 | $205.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.95 / $139.66 / $143.85
| Professional | | $101.95 | $139.66 | $143.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.66 / $139.66 / $205.51
| Facility | | $139.66 | $139.66 | $205.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.95 / $139.66 / $143.85
| Professional | | $101.95 | $139.66 | $143.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.00 / $165.63 / $323.25
| Professional | | $93.00 | $165.63 | $323.25 |