- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.52 / $242.43 / $4,950.59
| Facility | | $109.52 | $242.43 | $4,950.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $107.40 / $164.61
| Professional | | $106.33 | $107.40 | $164.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.33 / $171.47 / $339.19
| Facility | | $106.33 | $171.47 | $339.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $136.04
| Professional | | $106.33 | $106.33 | $136.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.32 / $106.33 / $149.11
| Facility | | $100.32 | $106.33 | $149.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $115.36
| Professional | | $106.33 | $106.33 | $115.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $109.52 / $129.83
| Professional | | $106.33 | $109.52 | $129.83 |