- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.32 / $106.33 / $994.75
| Professional | | $106.32 | $106.33 | $994.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.66 / $140.66 / $140.66
| Professional | | $140.66 | $140.66 | $140.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.32 / $185.21 / $308.69
| Facility | | $100.32 | $185.21 | $308.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $308.69
| Professional | | $106.33 | $106.33 | $308.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.32 / $185.21 / $308.69
| Facility | | $100.32 | $185.21 | $308.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $308.69
| Professional | | $106.33 | $106.33 | $308.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $112.71 / $318.99
| Professional | | $106.33 | $112.71 | $318.99 |