- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.15 / $157.10 / $184.78
| Professional | | $136.15 | $157.10 | $184.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.52 / $216.52 / $216.52
| Professional | | $216.52 | $216.52 | $216.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.00 / $142.00 / $146.03
| Facility | | $142.00 | $142.00 | $146.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.66 / $142.00 / $151.38
| Professional | | $103.66 | $142.00 | $151.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.00 / $142.00 / $146.03
| Facility | | $142.00 | $142.00 | $146.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.66 / $142.00 / $151.38
| Professional | | $103.66 | $142.00 | $151.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.57 / $178.04 / $322.20
| Professional | | $92.57 | $178.04 | $322.20 |