- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.61 / $155.61 / $155.61
| Facility | | $155.61 | $155.61 | $155.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $113.38 / $155.61
| Professional | | $111.15 | $113.38 | $155.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.86 / $104.86 / $111.15
| Facility | | $104.86 | $104.86 | $111.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $111.15
| Professional | | $111.15 | $111.15 | $111.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.86 / $198.77 / $474.00
| Facility | | $132.86 | $198.77 | $474.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.26 / $130.26 / $1,606.18
| Professional | | $130.26 | $130.26 | $1,606.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $161.16
| Professional | | $111.15 | $111.15 | $161.16 |