- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.15 / $217.22 / $429.22
| Professional | | $158.15 | $217.22 | $429.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.25 / $237.78 / $237.78
| Facility | | $184.25 | $237.78 | $237.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.00 / $541.32 / $541.32
| Professional | | $67.00 | $541.32 | $541.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.36 / $105.00 / $114.75
| Facility | | $91.36 | $105.00 | $114.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.36 / $114.75 / $159.90
| Professional | | $91.36 | $114.75 | $159.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.20 / $126.20 / $224.80
| Professional | | $126.20 | $126.20 | $224.80 |