- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.41 / $117.41 / $117.41
| Facility | | $117.41 | $117.41 | $117.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.41 / $139.81 / $167.75
| Professional | | $117.41 | $139.81 | $167.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.63 / $175.63 / $338.97
| Facility | | $147.63 | $175.63 | $338.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.63 / $175.63 / $236.60
| Professional | | $147.63 | $175.63 | $236.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $231.83
| Professional | | $141.06 | $141.06 | $231.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.90 / $189.39 / $257.11
| Professional | | $150.90 | $189.39 | $257.11 |