- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.54 / $101.03 / $172.45
| Facility | | $98.54 | $101.03 | $172.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $111.13
| Professional | | $101.03 | $101.03 | $111.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.54 / $105.46 / $205.08
| Professional | | $98.54 | $105.46 | $205.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $101.03
| Facility | | $101.03 | $101.03 | $101.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $101.03
| Professional | | $101.03 | $101.03 | $101.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.32 / $547.60 / $547.60
| Facility | | $174.32 | $547.60 | $547.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.64 / $466.64 / $466.64
| Professional | | $466.64 | $466.64 | $466.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $101.03
| Professional | | $101.03 | $101.03 | $101.03 |