- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.32 / $109.32 / $170.93
| Professional | | $109.32 | $109.32 | $170.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.63 / $190.63 / $190.63
| Facility | | $190.63 | $190.63 | $190.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.63 / $190.63 / $190.63
| Professional | | $190.63 | $190.63 | $190.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.78 / $107.78 / $211.37
| Facility | | $107.78 | $107.78 | $211.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.68 / $78.68 / $107.78
| Professional | | $78.68 | $78.68 | $107.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.97 / $85.28 / $85.28
| Facility | | $64.97 | $85.28 | $85.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.77 / $86.05 / $95.54
| Professional | | $77.77 | $86.05 | $95.54 |