- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.34 / $154.34 / $154.34
| Professional | | $154.34 | $154.34 | $154.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.00 / $183.00 / $228.75
| Professional | | $183.00 | $183.00 | $228.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.71 / $260.83 / $422.89
| Facility | | $220.71 | $260.83 | $422.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.31 / $133.31 / $133.31
| Professional | | $133.31 | $133.31 | $133.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.38 / $140.38 / $140.38
| Professional | | $140.38 | $140.38 | $140.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.83 / $130.83 / $130.83
| Professional | | $130.83 | $130.83 | $130.83 |