- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.10 / $193.10 / $193.10
| Facility | | $193.10 | $193.10 | $193.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $140.69 / $193.10
| Professional | | $137.93 | $140.69 | $193.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.12 / $137.93 / $137.93
| Facility | | $130.12 | $137.93 | $137.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Professional | | $137.93 | $137.93 | $137.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.77 / $137.93 / $299.08
| Facility | | $110.77 | $137.93 | $299.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.60 / $108.60 / $1,027.45
| Professional | | $108.60 | $108.60 | $1,027.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $234.48
| Professional | | $137.93 | $137.93 | $234.48 |