- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.07 / $153.91 / $2,313.65
| Facility | | $105.07 | $153.91 | $2,313.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $103.05 / $127.29
| Professional | | $101.03 | $103.05 | $127.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.58 / $101.03 / $116.18
| Facility | | $89.58 | $101.03 | $116.18 |
- 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
- $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
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $185.67
| Professional | | $101.03 | $101.03 | $185.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.98 / $101.03 / $106.08
| Professional | | $95.98 | $101.03 | $106.08 |