- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.06 / $160.06 / $160.06
| Facility | | $160.06 | $160.06 | $160.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.63 / $196.11 / $196.11
| Professional | | $154.63 | $196.11 | $196.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.70 / $243.21 / $249.26
| Professional | | $205.70 | $243.21 | $249.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.50 / $274.22 / $344.81
| Professional | | $271.50 | $274.22 | $344.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.27 / $160.06 / $917.84
| Facility | | $93.27 | $160.06 | $917.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.61 / $131.41 / $175.28
| Professional | | $87.61 | $131.41 | $175.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.40 / $131.41 / $208.41
| Professional | | $58.40 | $131.41 | $208.41 |