- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $92.41 / $110.55 / $161.72
| Facility | | $92.41 | $110.55 | $161.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.54 / $109.63 / $121.22
| Professional | | $91.54 | $109.63 | $121.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $141.06
| Professional | | $141.06 | $141.06 | $141.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $617.20 / $617.20 / $617.20
| Facility | | $617.20 | $617.20 | $617.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.22 / $882.23 / $1,314.08
| Professional | | $680.22 | $882.23 | $1,314.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.34 / $121.64 / $220.83
| Professional | | $101.34 | $121.64 | $220.83 |