- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $120.23 / $138.04
| Professional | | $97.72 | $120.23 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $199.53
| Facility | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $177.83
| Professional | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Facility | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $977.24 / $977.24
| Professional | | $263.03 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $128.82 / $302.00
| Professional | | $81.28 | $128.82 | $302.00 |