- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.58 / $170.95 / $170.95
| Professional | | $157.58 | $170.95 | $170.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.00 / $318.00 / $336.00
| Facility | | $306.00 | $318.00 | $336.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.00 / $324.00 / $324.00
| Professional | | $324.00 | $324.00 | $324.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.00 / $306.00 / $306.00
| Facility | | $306.00 | $306.00 | $306.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.00 / $306.00 / $306.00
| Professional | | $306.00 | $306.00 | $306.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $300.00 / $360.00
| Professional | | $300.00 | $300.00 | $360.00 |