- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.20 / $198.21 / $198.21
| Professional | | $180.20 | $198.21 | $198.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.78 / $168.78 / $451.52
| Facility | | $168.78 | $168.78 | $451.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.78 / $203.81 / $203.81
| Professional | | $168.78 | $203.81 | $203.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.78 / $168.78 / $451.52
| Facility | | $168.78 | $168.78 | $451.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.29 / $168.78 / $203.81
| Professional | | $101.29 | $168.78 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.63 / $205.63 / $218.36
| Professional | | $205.63 | $205.63 | $218.36 |