- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $125.89 / $234.42
| Facility | | $100.00 | $125.89 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $100.00 / $112.20
| Professional | | $89.13 | $100.00 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $91.20 / $93.33
| Professional | | $72.44 | $91.20 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $107.15
| Facility | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $109.65
| Professional | | $107.15 | $107.15 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.61 / $67.61 / $67.61
| Facility | | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $107.15
| Facility | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $107.15
| Professional | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $120.23 / $138.04
| Facility | | $114.82 | $120.23 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $109.65 / $117.49
| Professional | | $93.33 | $109.65 | $117.49 |