- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $196.70
| Facility | | $108.47 | $108.47 | $196.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.46 / $108.47 / $148.96
| Professional | | $108.46 | $108.47 | $148.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.68 / $118.27 / $119.79
| Facility | | $117.68 | $118.27 | $119.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.38 / $118.27 / $119.79
| Professional | | $100.38 | $118.27 | $119.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $154.80 / $194.64
| Professional | | $108.47 | $154.80 | $194.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.28 / $162.71 / $355.07
| Facility | | $109.28 | $162.71 | $355.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.28 / $124.58 / $1,698.40
| Professional | | $109.28 | $124.58 | $1,698.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $135.24
| Professional | | $108.47 | $108.47 | $135.24 |