- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.55 / $201.24 / $1,150.20
| Facility | | $109.55 | $201.24 | $1,150.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $109.54 / $148.96
| Professional | | $108.47 | $109.54 | $148.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.08 / $178.61 / $346.56
| Facility | | $110.08 | $178.61 | $346.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $127.45
| Professional | | $108.47 | $108.47 | $127.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $108.47 / $153.06
| Facility | | $102.33 | $108.47 | $153.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $138.13
| Professional | | $108.47 | $108.47 | $138.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $111.72 / $132.33
| Professional | | $108.47 | $111.72 | $132.33 |