- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.93 / $117.93 / $134.78
| Facility | | $117.93 | $117.93 | $134.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.32 / $117.93 / $134.78
| Professional | | $112.32 | $117.93 | $134.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.32 / $112.32 / $112.32
| Facility | | $112.32 | $112.32 | $112.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.32 / $112.32 / $112.32
| Professional | | $112.32 | $112.32 | $112.32 |
- 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
- $106.70 / $112.32 / $146.02
| Professional | | $106.70 | $112.32 | $146.02 |