- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.52 / $149.60 / $1,274.00
| Facility | | $138.52 | $149.60 | $1,274.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.47 / $139.94 / $187.89
| Professional | | $123.47 | $139.94 | $187.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.76 / $135.26 / $203.48
| Professional | | $115.76 | $135.26 | $203.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.08 / $172.97 / $253.07
| Professional | | $118.08 | $172.97 | $253.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.99 / $150.57 / $202.58
| Professional | | $115.99 | $150.57 | $202.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.47 / $165.71 / $205.32
| Professional | | $110.47 | $165.71 | $205.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.07 / $166.41 / $255.43
| Professional | | $125.07 | $166.41 | $255.43 |