- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.54 / $146.54 / $146.54
| Facility | | $146.54 | $146.54 | $146.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.54 / $146.54 / $146.54
| Professional | | $146.54 | $146.54 | $146.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.00 / $192.00 / $192.00
| Professional | | $192.00 | $192.00 | $192.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.76 / $165.76 / $165.76
| Professional | | $165.76 | $165.76 | $165.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.72 / $232.72 / $710.71
| Professional | | $232.72 | $232.72 | $710.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.08 / $178.62 / $268.38
| Professional | | $119.08 | $178.62 | $268.38 |