- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $40.74 / $141.25
| Professional | | $30.20 | $40.74 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $141.25 / $165.96
| Facility | | $102.33 | $141.25 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $51.29 / $75.86
| Professional | | $38.90 | $51.29 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.36 / $46.77 / $47.86
| Facility | | $32.36 | $46.77 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $33.88 / $46.77
| Professional | | $33.88 | $33.88 | $46.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.66 / $57.54 / $89.13
| Facility | | $42.66 | $57.54 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.62 / $40.74 / $58.88
| Professional | | $31.62 | $40.74 | $58.88 |