- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.25 / $196.25 / $245.32
| Professional | | $196.25 | $196.25 | $245.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.92 / $186.59 / $303.87
| Facility | | $75.92 | $186.59 | $303.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.65 / $396.65 / $396.65
| Professional | | $396.65 | $396.65 | $396.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.00 / $145.00 / $145.00
| Facility | | $145.00 | $145.00 | $145.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.00 / $138.00 / $178.73
| Professional | | $133.00 | $138.00 | $178.73 |