- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $213.80
| Professional | | $162.18 | $162.18 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $177.83 / $239.88
| Facility | | $151.36 | $177.83 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $331.13
| Professional | | $204.17 | $204.17 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $186.21 / $194.98
| Facility | | $158.49 | $186.21 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $186.21 / $218.78
| Professional | | $162.18 | $186.21 | $218.78 |