- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.46 / $203.46 / $203.46
| Facility | | $203.46 | $203.46 | $203.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.55 / $223.25 / $275.00
| Professional | | $192.55 | $223.25 | $275.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.98 / $101.98 / $101.98
| Facility | | $101.98 | $101.98 | $101.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.00 / $225.00 / $275.00
| Professional | | $225.00 | $225.00 | $275.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.31 / $238.84 / $311.54
| Professional | | $197.31 | $238.84 | $311.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.96 / $315.62 / $315.63
| Facility | | $103.96 | $315.62 | $315.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.45 / $180.36 / $319.57
| Professional | | $101.45 | $180.36 | $319.57 |