- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.38 / $115.38 / $133.13
| Professional | | $115.38 | $115.38 | $133.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.22 / $135.22 / $135.22
| Facility | | $135.22 | $135.22 | $135.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.72 / $181.64 / $193.57
| Professional | | $98.72 | $181.64 | $193.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.22 / $135.22 / $135.22
| Facility | | $135.22 | $135.22 | $135.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.72 / $181.80 / $193.57
| Professional | | $98.72 | $181.80 | $193.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.63 / $140.05 / $273.33
| Professional | | $78.63 | $140.05 | $273.33 |