- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.15 / $167.15 / $173.94
| Facility | | $167.15 | $167.15 | $173.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.62 / $138.68 / $309.01
| Professional | | $127.62 | $138.68 | $309.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.00 / $710.00 / $710.00
| Professional | | $432.00 | $710.00 | $710.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.63 / $332.02 / $568.86
| Professional | | $239.63 | $332.02 | $568.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.47 / $346.19 / $878.89
| Professional | | $271.47 | $346.19 | $878.89 |