- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $128.82 / $141.25
| Professional | | $100.00 | $128.82 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $177.83
| Facility | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $190.55 / $190.55
| Professional | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $154.88
| Facility | | $151.36 | $151.36 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $181.97
| Professional | | $112.20 | $112.20 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $229.09 / $281.84
| Professional | | $181.97 | $229.09 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $131.83
| Facility | | $104.71 | $104.71 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $162.18 / $489.78
| Professional | | $81.28 | $162.18 | $489.78 |