- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.96 / $201.68 / $252.10
| Professional | | $173.96 | $201.68 | $252.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.63 / $266.74 / $1,024.71
| Facility | | $208.63 | $266.74 | $1,024.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.29 / $1,138.00 / $1,138.00
| Professional | | $208.29 | $1,138.00 | $1,138.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $222.00 / $222.00 / $222.00
| Facility | | $222.00 | $222.00 | $222.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.55 / $208.29 / $327.00
| Professional | | $189.55 | $208.29 | $327.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.50 / $298.50 / $298.50
| Professional | | $298.50 | $298.50 | $298.50 |