- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.47 / $574.60 / $574.60
| Professional | | $78.47 | $574.60 | $574.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.82 / $185.27 / $185.27
| Facility | | $121.82 | $185.27 | $185.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.82 / $150.66 / $185.27
| Professional | | $121.82 | $150.66 | $185.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.37 / $176.45 / $185.27
| Facility | | $98.37 | $176.45 | $185.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.82 / $139.05 / $185.40
| Professional | | $121.82 | $139.05 | $185.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.56 / $88.03 / $134.69
| Professional | | $79.56 | $88.03 | $134.69 |