- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.08 / $120.17 / $141.52
| Professional | | $108.08 | $120.17 | $141.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.74 / $155.72 / $169.67
| Facility | | $142.74 | $155.72 | $169.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.82 / $150.82 / $150.82
| Professional | | $150.82 | $150.82 | $150.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $216.44 / $216.44 / $216.44
| Facility | | $216.44 | $216.44 | $216.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.41 / $88.16 / $262.61
| Professional | | $59.41 | $88.16 | $262.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.39 / $159.74 / $287.52
| Professional | | $93.39 | $159.74 | $287.52 |