- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.30 / $174.30 / $201.11
| Professional | | $174.30 | $174.30 | $201.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.57 / $218.57 / $262.52
| Facility | | $218.57 | $218.57 | $262.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.56 / $218.57 / $225.13
| Professional | | $159.56 | $218.57 | $225.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.57 / $218.57 / $262.52
| Facility | | $218.57 | $218.57 | $262.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.56 / $218.57 / $225.13
| Professional | | $159.56 | $218.57 | $225.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.55 / $211.58 / $412.91
| Professional | | $123.55 | $211.58 | $412.91 |