- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.54 / $101.03 / $7,487.72
| Facility | | $98.54 | $101.03 | $7,487.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $108.34
| Professional | | $101.03 | $101.03 | $108.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.31 / $101.03 / $101.03
| Facility | | $95.31 | $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
- $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 / $110.07
| Professional | | $101.03 | $101.03 | $110.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $157.13 / $564.21
| Professional | | $40.00 | $157.13 | $564.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $102.04
| Professional | | $101.03 | $101.03 | $102.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.54 / $101.03 / $101.03
| Professional | | $98.54 | $101.03 | $101.03 |