- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,371.30 / $5,371.30 / $5,607.39
| Facility | | $5,371.30 | $5,371.30 | $5,607.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.46 / $112.81 / $132.22
| Professional | | $108.46 | $112.81 | $132.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $96.47 / $120.59 / $343.74
| Facility | | $96.47 | $120.59 | $343.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $112.56
| Professional | | $108.47 | $108.47 | $112.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $163.28
| Facility | | $108.47 | $108.47 | $163.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $108.47
| Professional | | $108.47 | $108.47 | $108.47 |
- 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
- $5,371.30 / $5,371.30 / $5,607.39
| Facility | | $5,371.30 | $5,371.30 | $5,607.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $118.66 / $148.96
| Professional | | $108.47 | $118.66 | $148.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $162.71
| Professional | | $108.47 | $108.47 | $162.71 |