- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $275.42 / $630.96
| Facility | | $100.00 | $275.42 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $263.03 / $501.19
| Professional | | $128.82 | $263.03 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $208.93 / $338.84
| Professional | | $144.54 | $208.93 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $331.13 / $741.31
| Professional | | $162.18 | $331.13 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $407.38 / $741.31
| Professional | | $177.83 | $407.38 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.83 / $269.15 / $416.87
| Facility | | $0.83 | $269.15 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $275.42 / $660.69
| Professional | | $144.54 | $275.42 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $269.15 / $630.96
| Professional | | $138.04 | $269.15 | $630.96 |