- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.07 / $110.07 / $110.07
| Professional | | $110.07 | $110.07 | $110.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.62 / $220.19 / $260.70
| Professional | | $56.62 | $220.19 | $260.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.82 / $149.31 / $219.85
| Professional | | $102.82 | $149.31 | $219.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.53 / $199.84 / $361.50
| Professional | | $166.53 | $199.84 | $361.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.07 / $110.07 / $121.73
| Professional | | $110.07 | $110.07 | $121.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.43 / $126.63 / $330.32
| Professional | | $82.43 | $126.63 | $330.32 |