- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $352.53 / $352.53 / $4,914.09
| Facility | | $352.53 | $352.53 | $4,914.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.46 / $108.47 / $112.81
| Professional | | $108.46 | $108.47 | $112.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.28 / $109.28 / $163.28
| Facility | | $109.28 | $109.28 | $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
- Facility
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $108.47
| Facility | | $108.47 | $108.47 | $108.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $153.49
| Professional | | $108.47 | $108.47 | $153.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $120.75
| Professional | | $108.47 | $108.47 | $120.75 |