- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $464.00 / $464.00 / $464.00
| Facility | | $464.00 | $464.00 | $464.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.45 / $143.82 / $275.63
| Professional | | $78.45 | $143.82 | $275.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.28 / $161.72 / $254.00
| Professional | | $98.28 | $161.72 | $254.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.69 / $192.45 / $322.76
| Professional | | $108.69 | $192.45 | $322.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.84 / $206.10 / $346.99
| Professional | | $122.84 | $206.10 | $346.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $464.00 / $464.00 / $464.00
| Facility | | $464.00 | $464.00 | $464.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.45 / $143.82 / $286.43
| Professional | | $78.45 | $143.82 | $286.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.93 / $205.52 / $346.99
| Professional | | $127.93 | $205.52 | $346.99 |