- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.45 / $571.05 / $571.05
| Professional | | $97.45 | $571.05 | $571.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.67 / $176.67 / $176.67
| Facility | | $176.67 | $176.67 | $176.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.27 / $176.67 / $176.67
| Professional | | $130.27 | $176.67 | $176.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.61 / $178.10 / $184.69
| Facility | | $86.61 | $178.10 | $184.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.08 / $160.63 / $231.70
| Professional | | $107.08 | $160.63 | $231.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.15 / $190.23 / $309.87
| Professional | | $154.15 | $190.23 | $309.87 |