- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.21 / $272.08 / $5,084.80
| Facility | | $144.21 | $272.08 | $5,084.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $164.61
| Professional | | $106.33 | $106.33 | $164.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.96 / $186.69 / $340.26
| Facility | | $116.96 | $186.69 | $340.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $106.33
| Professional | | $106.33 | $106.33 | $106.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.32 / $100.32 / $233.29
| Facility | | $100.32 | $100.32 | $233.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $106.33
| Professional | | $106.33 | $106.33 | $106.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.71 / $136.04 / $237.48
| Facility | | $112.71 | $136.04 | $237.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.90 / $116.97 / $160.56
| Professional | | $115.90 | $116.97 | $160.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $112.71
| Professional | | $106.33 | $106.33 | $112.71 |