- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.36 / $280.87 / $718.54
| Facility | | $108.36 | $280.87 | $718.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.00 / $108.36 / $302.39
| Professional | | $96.00 | $108.36 | $302.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.80 / $188.48 / $387.81
| Facility | | $132.80 | $188.48 | $387.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.24 / $106.24 / $106.24
| Professional | | $106.24 | $106.24 | $106.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $108.36
| Facility | | $108.36 | $108.36 | $108.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $108.36
| Professional | | $108.36 | $108.36 | $108.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.68 / $151.62 / $151.62
| Professional | | $139.68 | $151.62 | $151.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $106.24 / $117.28
| Professional | | $101.03 | $106.24 | $117.28 |