- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.97 / $110.97 / $110.97
| Facility | | $110.97 | $110.97 | $110.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.70 / $106.70 / $110.97
| Professional | | $106.70 | $106.70 | $110.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $262.64 / $357.22 / $396.91
| Facility | | $262.64 | $357.22 | $396.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.66 / $106.70 / $106.70
| Facility | | $100.66 | $106.70 | $106.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.70 / $106.70 / $106.70
| Professional | | $106.70 | $106.70 | $106.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.70 / $106.70 / $106.70
| Professional | | $106.70 | $106.70 | $106.70 |