- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.68 / $103.68 / $103.68
| Facility | | $103.68 | $103.68 | $103.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.40 / $103.68 / $147.65
| Professional | | $103.40 | $103.68 | $147.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.83 / $166.61 / $260.73
| Professional | | $133.83 | $166.61 | $260.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.62 / $175.62 / $175.62
| Professional | | $175.62 | $175.62 | $175.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.68 / $132.19 / $196.72
| Facility | | $103.68 | $132.19 | $196.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.43 / $233.03 / $284.48
| Professional | | $163.43 | $233.03 | $284.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $730.00 / $1,464.00 / $3,011.00
| Facility | | $730.00 | $1,464.00 | $3,011.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.70 / $242.79 / $398.03
| Professional | | $189.70 | $242.79 | $398.03 |