- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $96.81 / $138.15 / $942.87
| Facility | | $96.81 | $138.15 | $942.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.98 / $103.26 / $105.81
| Professional | | $101.98 | $103.26 | $105.81 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $103.26 / $117.72 / $217.02
| Facility | | $103.26 | $117.72 | $217.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.24 / $106.24 / $130.25
| Professional | | $106.24 | $106.24 | $130.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.24 / $106.24 / $112.61
| Professional | | $106.24 | $106.24 | $112.61 |