- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.06 / $177.06 / $177.06
| Facility | | $177.06 | $177.06 | $177.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.93 / $177.06 / $294.58
| Professional | | $168.93 | $177.06 | $294.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $395.80 / $476.31
| Professional | | $250.00 | $395.80 | $476.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $277.45 / $277.45 / $306.33
| Facility | | $277.45 | $277.45 | $306.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.54 / $267.08 / $277.45
| Professional | | $202.54 | $267.08 | $277.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.06 / $294.58 / $640.44
| Facility | | $177.06 | $294.58 | $640.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.14 / $297.14 / $297.14
| Professional | | $297.14 | $297.14 | $297.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.96 / $197.46 / $303.54
| Professional | | $132.96 | $197.46 | $303.54 |