- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.02 / $108.02 / $108.02
| Facility | | $108.02 | $108.02 | $108.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.88 / $107.88 / $108.02
| Professional | | $107.88 | $107.88 | $108.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.82 / $164.14 / $168.22
| Professional | | $138.82 | $164.14 | $168.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.00 / $181.80 / $228.60
| Professional | | $180.00 | $181.80 | $228.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.94 / $108.02 / $757.74
| Facility | | $80.94 | $108.02 | $757.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.15 / $80.41 / $120.71
| Professional | | $59.15 | $80.41 | $120.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.28 / $80.41 / $172.31
| Professional | | $48.28 | $80.41 | $172.31 |