- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.56 / $138.56 / $226.84
| Facility | | $138.56 | $138.56 | $226.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.00 / $137.13 / $138.56
| Professional | | $113.00 | $137.13 | $138.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.20 / $273.62 / $323.27
| Professional | | $252.20 | $273.62 | $323.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.53 / $249.94 / $349.52
| Professional | | $198.53 | $249.94 | $349.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.56 / $198.52 / $345.37
| Facility | | $138.56 | $198.52 | $345.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.38 / $277.12 / $1,174.00
| Professional | | $142.38 | $277.12 | $1,174.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.31 / $256.00 / $347.37
| Professional | | $139.31 | $256.00 | $347.37 |