- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.81 / $310.89 / $588.00
| Facility | | $105.81 | $310.89 | $588.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.81 / $455.20 / $1,461.60
| Professional | | $105.81 | $455.20 | $1,461.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.21 / $111.55 / $338.91
| Facility | | $97.21 | $111.55 | $338.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.24 / $108.36 / $113.16
| Professional | | $106.24 | $108.36 | $113.16 |
- 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
- $127.48 / $127.48 / $256.13
| Professional | | $127.48 | $127.48 | $256.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.24 / $106.24 / $106.24
| Professional | | $106.24 | $106.24 | $106.24 |