- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.25 / $100.31 / $118.59
| Professional | | $80.25 | $100.31 | $118.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.88 / $127.17 / $127.17
| Facility | | $112.88 | $127.17 | $127.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.93 / $222.93 / $322.97
| Professional | | $222.93 | $222.93 | $322.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.35 / $98.35 / $115.04
| Facility | | $98.35 | $98.35 | $115.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.37 / $220.37 / $220.37
| Professional | | $220.37 | $220.37 | $220.37 |