- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $120.23 / $162.18
| Professional | | $100.00 | $120.23 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $213.80 / $229.09
| Facility | | $151.36 | $213.80 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $125.89 / $213.80
| Professional | | $102.33 | $125.89 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.88 / $112.20 / $190.55
| Facility | | $58.88 | $112.20 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $147.91 / $851.14
| Professional | | $120.23 | $147.91 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $141.25 / $186.21
| Professional | | $114.82 | $141.25 | $186.21 |