- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.04 / $132.65 / $176.87
| Facility | | $105.04 | $132.65 | $176.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $130.77 / $163.29
| Professional | | $104.71 | $130.77 | $163.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.00 / $525.00 / $525.00
| Facility | | $525.00 | $525.00 | $525.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.88 / $139.47 / $187.30
| Professional | | $109.88 | $139.47 | $187.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $104.00 / $179.55
| Professional | | $70.00 | $104.00 | $179.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.00 / $104.00 / $179.55
| Professional | | $71.00 | $104.00 | $179.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.30 / $159.44 / $336.69
| Professional | | $110.30 | $159.44 | $336.69 |