- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.23 / $206.48 / $1,200.00
| Facility | | $125.23 | $206.48 | $1,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.23 / $190.14 / $294.25
| Professional | | $125.23 | $190.14 | $294.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.25 / $174.22 / $239.85
| Facility | | $140.25 | $174.22 | $239.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.95 / $154.86 / $154.86
| Professional | | $104.95 | $154.86 | $154.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.88 / $224.88 / $224.88
| Facility | | $224.88 | $224.88 | $224.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.72 / $224.66 / $496.77
| Professional | | $147.72 | $224.66 | $496.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.96 / $214.64 / $300.86
| Professional | | $140.96 | $214.64 | $300.86 |