- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,523.98 / $8,523.98 / $8,523.98
| Facility | | $8,523.98 | $8,523.98 | $8,523.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.62 / $102.43 / $141.57
| Professional | | $74.62 | $102.43 | $141.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.78 / $114.58 / $172.94
| Professional | | $96.78 | $114.58 | $172.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.92 / $135.99 / $188.53
| Professional | | $96.92 | $135.99 | $188.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.09 / $130.19 / $199.73
| Professional | | $101.09 | $130.19 | $199.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,523.98 / $8,523.98 / $8,523.98
| Facility | | $8,523.98 | $8,523.98 | $8,523.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.82 / $102.43 / $141.57
| Professional | | $85.82 | $102.43 | $141.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.84 / $140.82 / $199.73
| Professional | | $110.84 | $140.82 | $199.73 |