- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.54 / $107.54 / $124.09
| Professional | | $107.54 | $107.54 | $124.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.31 / $122.31 / $161.97
| Facility | | $122.31 | $122.31 | $161.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.29 / $122.31 / $130.38
| Professional | | $89.29 | $122.31 | $130.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.31 / $122.31 / $161.97
| Facility | | $122.31 | $122.31 | $161.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.29 / $122.31 / $130.38
| Professional | | $89.29 | $122.31 | $130.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.23 / $165.62 / $254.77
| Professional | | $76.23 | $165.62 | $254.77 |