- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $208.93 / $457.09
| Facility | | $107.15 | $208.93 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $107.15 / $144.54
| Professional | | $104.71 | $107.15 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $120.23 / $120.23
| Facility | | $114.82 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $104.71 / $104.71
| Facility | | $100.00 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $109.65 / $162.18
| Facility | | $100.00 | $109.65 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $102.33 / $426.58
| Professional | | $100.00 | $102.33 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $104.71
| Facility | | $100.00 | $100.00 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $104.71 / $117.49
| Professional | | $97.72 | $104.71 | $117.49 |