- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.47 / $191.85 / $310.86
| Professional | | $153.47 | $191.85 | $310.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.12 / $296.22 / $395.46
| Facility | | $145.12 | $296.22 | $395.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.00 / $1,367.00 / $1,367.00
| Professional | | $347.00 | $1,367.00 | $1,367.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.00 / $258.00 / $258.00
| Facility | | $258.00 | $258.00 | $258.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.31 / $258.00 / $274.87
| Professional | | $153.31 | $258.00 | $274.87 |