- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.01 / $162.13 / $316.52
| Professional | | $95.01 | $162.13 | $316.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.00 / $205.30 / $205.30
| Facility | | $147.00 | $205.30 | $205.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.30 / $401.42 / $414.09
| Professional | | $132.30 | $401.42 | $414.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.56 / $147.00 / $147.00
| Facility | | $97.56 | $147.00 | $147.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.56 / $124.50 / $164.35
| Professional | | $97.56 | $124.50 | $164.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.90 / $106.90 / $210.10
| Professional | | $106.90 | $106.90 | $210.10 |