- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.36 / $180.77 / $395.70
| Facility | | $120.36 | $180.77 | $395.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Professional | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.30 / $179.38 / $353.71
| Facility | | $100.30 | $179.38 | $353.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.00 / $118.00 / $120.36
| Professional | | $118.00 | $118.00 | $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
- $120.36 / $120.36 / $120.36
| Professional | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.20 / $118.00 / $130.27
| Professional | | $106.20 | $118.00 | $130.27 |