- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.43 / $567.13 / $567.13
| Professional | | $101.43 | $567.13 | $567.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.89 / $149.94 / $502.74
| Facility | | $127.89 | $149.94 | $502.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.89 / $127.89 / $127.89
| Professional | | $127.89 | $127.89 | $127.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.89 / $149.94 / $502.74
| Facility | | $127.89 | $149.94 | $502.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.38 / $79.38 / $127.89
| Professional | | $79.38 | $79.38 | $127.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.04 / $37.04 / $88.20
| Professional | | $37.04 | $37.04 | $88.20 |