- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.01 / $238.98 / $265.20
| Professional | | $193.01 | $238.98 | $265.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.44 / $336.44 / $357.47
| Professional | | $336.44 | $336.44 | $357.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.13 / $180.13 / $180.13
| Facility | | $180.13 | $180.13 | $180.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.11 / $180.13 / $180.13
| Professional | | $153.11 | $180.13 | $180.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.01 / $238.98 / $287.22
| Facility | | $193.01 | $238.98 | $287.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.00 / $1,151.00 / $1,151.00
| Professional | | $1,151.00 | $1,151.00 | $1,151.00 |