- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.80 / $155.80 / $228.00
| Facility | | $155.80 | $155.80 | $228.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.00 / $161.50 / $228.00
| Professional | | $152.00 | $161.50 | $228.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.32 / $5.32 / $5.32
| Professional | | $5.32 | $5.32 | $5.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.50 / $161.50 / $161.50
| Facility | | $161.50 | $161.50 | $161.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.50 / $161.50 / $161.50
| Professional | | $161.50 | $161.50 | $161.50 |
- 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
- $158.36 / $167.51 / $217.76
| Professional | | $158.36 | $167.51 | $217.76 |