- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $101.72
| Facility | | $101.72 | $101.72 | $101.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $109.85
| Professional | | $101.72 | $101.72 | $109.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $102.18 / $218.74
| Facility | | $1.00 | $102.18 | $218.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.58 / $100.72 / $113.68
| Professional | | $80.58 | $100.72 | $113.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.56 / $302.39 / $425.04
| Facility | | $164.56 | $302.39 | $425.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.14 / $127.44 / $132.21
| Professional | | $105.14 | $127.44 | $132.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.15 / $277.13 / $383.03
| Facility | | $146.15 | $277.13 | $383.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.10 / $104.10 / $116.92
| Professional | | $104.10 | $104.10 | $116.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.72 / $100.72 / $221.69
| Facility | | $100.72 | $100.72 | $221.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.72 / $100.72 / $231.04
| Professional | | $100.72 | $100.72 | $231.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $188.59
| Professional | | $101.72 | $101.72 | $188.59 |