- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.36 / $148.09 / $588.04
| Facility | | $120.36 | $148.09 | $588.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.40 / $117.53 / $120.36
| Professional | | $115.40 | $117.53 | $120.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.30 / $175.60 / $338.24
| Facility | | $100.30 | $175.60 | $338.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.00 / $119.74 / $120.36
| Professional | | $118.00 | $119.74 | $120.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Facility | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Professional | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.00 / $118.00 / $128.15
| Professional | | $118.00 | $118.00 | $128.15 |