- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.64 / $127.45 / $169.93
| Facility | | $109.64 | $127.45 | $169.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.35 / $131.54 / $170.16
| Professional | | $107.35 | $131.54 | $170.16 |
- 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
- $178.65 / $202.47 / $238.20
| Professional | | $178.65 | $202.47 | $238.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $172.34 / $254.72
| Professional | | $100.00 | $172.34 | $254.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $172.34 / $258.75
| Professional | | $100.00 | $172.34 | $258.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.98 / $146.00 / $322.69
| Professional | | $105.98 | $146.00 | $322.69 |