- 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 / $111.13
| Professional | | $101.03 | $101.03 | $111.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $98.54 / $240.78
| Facility | | $1.00 | $98.54 | $240.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.83 / $98.54 / $103.77
| Professional | | $78.83 | $98.54 | $103.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.12 / $296.08 / $416.18
| Facility | | $161.12 | $296.08 | $416.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.51 / $124.78 / $136.44
| Professional | | $108.51 | $124.78 | $136.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.10 / $271.35 / $375.04
| Facility | | $143.10 | $271.35 | $375.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.44 / $107.44 / $114.48
| Professional | | $107.44 | $107.44 | $114.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.54 / $98.54 / $217.41
| Facility | | $98.54 | $98.54 | $217.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.54 / $98.54 / $226.04
| Professional | | $98.54 | $98.54 | $226.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $183.15
| Professional | | $101.03 | $101.03 | $183.15 |