- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.62 / $122.62 / $323.00
| Professional | | $112.62 | $122.62 | $323.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.57 / $176.22 / $218.12
| Professional | | $164.57 | $176.22 | $218.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.01 / $170.34 / $278.33
| Professional | | $122.01 | $170.34 | $278.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.77 / $170.34 / $278.33
| Professional | | $123.77 | $170.34 | $278.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.04 / $174.82 / $274.41
| Professional | | $127.04 | $174.82 | $274.41 |