- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.61 / $101.61 / $111.01
| Facility | | $101.61 | $101.61 | $111.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.72 / $108.16 / $190.18
| Professional | | $99.72 | $108.16 | $190.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.56 / $203.26 / $203.26
| Professional | | $134.56 | $203.26 | $203.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.72 / $141.12 / $141.12
| Facility | | $120.72 | $141.12 | $141.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.02 / $103.02 / $141.12
| Professional | | $103.02 | $103.02 | $141.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $451.67 / $1,262.20 / $1,430.27
| Facility | | $451.67 | $1,262.20 | $1,430.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,381.35 / $3,462.48 / $3,462.48
| Professional | | $3,381.35 | $3,462.48 | $3,462.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.50 / $150.50 / $150.50
| Facility | | $150.50 | $150.50 | $150.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.11 / $110.32 / $161.63
| Professional | | $75.11 | $110.32 | $161.63 |