- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.47 / $109.28 / $146.43
| Facility | | $108.47 | $109.28 | $146.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $130.16
| Professional | | $108.47 | $108.47 | $130.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.28 / $109.28 / $109.28
| Professional | | $109.28 | $109.28 | $109.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,921.89 / $2,332.31 / $3,137.71
| Facility | | $1,921.89 | $2,332.31 | $3,137.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.13 / $138.13 / $138.13
| Professional | | $138.13 | $138.13 | $138.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $108.47
| Facility | | $108.47 | $108.47 | $108.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $192.09
| Professional | | $108.47 | $108.47 | $192.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.20 / $108.47 / $122.46
| Professional | | $92.20 | $108.47 | $122.46 |