- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.47 / $218.56 / $4,726.02
| Facility | | $108.47 | $218.56 | $4,726.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $132.22
| Professional | | $108.47 | $108.47 | $132.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.32 / $190.45 / $347.10
| Facility | | $119.32 | $190.45 | $347.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $108.47
| Professional | | $108.47 | $108.47 | $108.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $206.34
| Facility | | $102.33 | $102.33 | $206.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $108.47
| Professional | | $108.47 | $108.47 | $108.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.28 / $114.98 / $292.54
| Facility | | $109.28 | $114.98 | $292.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.23 / $119.31 / $163.79
| Professional | | $118.23 | $119.31 | $163.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $114.98
| Professional | | $108.47 | $108.47 | $114.98 |