- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.87 / $134.11 / $142.33
| Facility | | $108.87 | $134.11 | $142.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.80 / $134.11 / $149.88
| Professional | | $101.80 | $134.11 | $149.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.07 / $211.07 / $316.61
| Facility | | $211.07 | $211.07 | $316.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.07 / $211.07 / $215.29
| Professional | | $211.07 | $211.07 | $215.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,323.62 / $10,323.62 / $10,323.62
| Facility | | $10,323.62 | $10,323.62 | $10,323.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.77 / $342.87 / $411.44
| Professional | | $325.77 | $342.87 | $411.44 |