- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.18 / $192.18 / $198.24
| Facility | | $192.18 | $192.18 | $198.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.61 / $194.20 / $203.51
| Professional | | $138.61 | $194.20 | $203.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.10 / $186.10 / $186.10
| Facility | | $186.10 | $186.10 | $186.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.10 / $186.10 / $186.10
| Professional | | $186.10 | $186.10 | $186.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.26 / $94.26 / $206.54
| Professional | | $94.26 | $94.26 | $206.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.31 / $108.39 / $228.21
| Professional | | $65.31 | $108.39 | $228.21 |