- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $186.21 / $331.13
| Facility | | $114.82 | $186.21 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $114.82 / $263.03
| Professional | | $112.20 | $114.82 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $173.78 / $346.74
| Facility | | $134.90 | $173.78 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Professional | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Professional | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $112.20 / $138.04
| Professional | | $109.65 | $112.20 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $112.20 / $263.03
| Professional | | $100.00 | $112.20 | $263.03 |