- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.17 / $133.50 / $187.63
| Professional | | $106.17 | $133.50 | $187.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.44 / $457.44 / $457.44
| Professional | | $457.44 | $457.44 | $457.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.03 / $176.51 / $176.51
| Professional | | $120.03 | $176.51 | $176.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $541.00 / $541.00 / $541.00
| Facility | | $541.00 | $541.00 | $541.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.25 / $159.77 / $219.21
| Professional | | $120.25 | $159.77 | $219.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.88 / $151.88 / $192.02
| Professional | | $120.88 | $151.88 | $192.02 |