- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.94 / $120.94 / $120.94
| Facility | | $120.94 | $120.94 | $120.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.75 / $96.75 / $120.94
| Professional | | $96.75 | $96.75 | $120.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.80 / $102.80 / $102.80
| Facility | | $102.80 | $102.80 | $102.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.80 / $102.80 / $102.80
| Professional | | $102.80 | $102.80 | $102.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $96.75 / $120.94 / $131.82
| Facility | | $96.75 | $120.94 | $131.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.78 / $100.78 / $459.57
| Professional | | $100.78 | $100.78 | $459.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.78 / $100.78 / $146.13
| Professional | | $100.78 | $100.78 | $146.13 |