- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $208.93 / $588.84
| Facility | | $104.71 | $208.93 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $128.82 / $489.78
| Professional | | $104.71 | $128.82 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $144.54 / $302.00
| Facility | | $114.82 | $144.54 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $158.49
| Professional | | $104.71 | $104.71 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $104.71 / $223.87
| Facility | | $100.00 | $104.71 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $109.65 / $134.90
| Professional | | $104.71 | $109.65 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $112.20 / $239.88
| Facility | | $104.71 | $112.20 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $154.88
| Professional | | $104.71 | $104.71 | $154.88 |