- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.81 / $412.74 / $412.74
| Professional | | $73.81 | $412.74 | $412.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.08 / $125.17 / $189.68
| Facility | | $93.08 | $125.17 | $189.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.41 / $91.89 / $93.08
| Professional | | $20.41 | $91.89 | $93.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.08 / $125.17 / $189.68
| Facility | | $93.08 | $125.17 | $189.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.77 / $57.77 / $93.08
| Professional | | $57.77 | $57.77 | $93.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $26.96 / $64.19
| Professional | | $16.98 | $26.96 | $64.19 |