- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.02 / $125.39 / $125.39
| Professional | | $118.02 | $125.39 | $125.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.02 / $221.28 / $258.16
| Facility | | $177.02 | $221.28 | $258.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.02 / $177.02 / $199.15
| Professional | | $177.02 | $177.02 | $199.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $351.78 / $351.78 / $351.78
| Facility | | $351.78 | $351.78 | $351.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.78 / $276.52 / $947.48
| Professional | | $255.78 | $276.52 | $947.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.14 / $129.22 / $298.87
| Professional | | $81.14 | $129.22 | $298.87 |