- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.48 / $115.78 / $132.02
| Professional | | $101.48 | $115.78 | $132.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.02 / $194.02 / $194.02
| Facility | | $194.02 | $194.02 | $194.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.39 / $181.77 / $360.00
| Professional | | $118.39 | $181.77 | $360.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.08 / $165.94 / $229.60
| Facility | | $124.08 | $165.94 | $229.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.45 / $178.59 / $273.73
| Professional | | $119.45 | $178.59 | $273.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.24 / $203.57 / $253.34
| Professional | | $165.24 | $203.57 | $253.34 |