- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.47 / $145.47 / $188.14
| Facility | | $145.47 | $145.47 | $188.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.06 / $157.22 / $244.89
| Professional | | $118.06 | $157.22 | $244.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.00 / $235.00 / $235.00
| Professional | | $235.00 | $235.00 | $235.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.87 / $172.94 / $246.13
| Professional | | $116.87 | $172.94 | $246.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.71 / $189.52 / $295.62
| Professional | | $150.71 | $189.52 | $295.62 |