- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $181.97 / $338.84
| Facility | | $104.71 | $181.97 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $138.04
| Professional | | $104.71 | $104.71 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $144.54 / $316.23
| Facility | | $109.65 | $144.54 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $141.25
| Professional | | $104.71 | $104.71 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $104.71 / $147.91
| Facility | | $100.00 | $104.71 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $125.89
| Professional | | $104.71 | $104.71 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.72 / $104.71 / $173.78
| Facility | | $97.72 | $104.71 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $104.71 / $117.49
| Professional | | $100.00 | $104.71 | $117.49 |