- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.11 / $152.35 / $3,354.15
| Facility | | $109.11 | $152.35 | $3,354.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.04 / $109.11 / $109.11
| Professional | | $102.04 | $109.11 | $109.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.31 / $95.31 / $101.03
| Facility | | $95.31 | $95.31 | $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
- $104.83 / $111.74 / $205.08
| Facility | | $104.83 | $111.74 | $205.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.54 / $98.54 / $145.57
| Professional | | $98.54 | $98.54 | $145.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $111.41
| Professional | | $101.03 | $101.03 | $111.41 |