- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $242.24
| Professional | | $141.60 | $141.60 | $242.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.31 / $160.31 / $160.31
| Facility | | $160.31 | $160.31 | $160.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.59 / $154.59 / $257.64
| Facility | | $133.59 | $154.59 | $257.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $141.60
| Professional | | $141.60 | $141.60 | $141.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.59 / $154.59 / $257.64
| Facility | | $133.59 | $154.59 | $257.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $141.60
| Professional | | $141.60 | $141.60 | $141.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.52 / $141.60 / $217.82
| Professional | | $134.52 | $141.60 | $217.82 |