- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $263.03
| Facility | | $162.18 | $162.18 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $131.83 / $158.49
| Professional | | $109.65 | $131.83 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $1,288.25 / $1,412.54
| Facility | | $190.55 | $1,288.25 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $97.72 / $204.17
| Professional | | $66.07 | $97.72 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $194.98
| Professional | | $162.18 | $162.18 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Facility | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $131.83 / $158.49
| Professional | | $109.65 | $131.83 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $162.18 / $302.00
| Professional | | $97.72 | $162.18 | $302.00 |