- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.36 / $238.98 / $271.55
| Professional | | $141.36 | $238.98 | $271.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.83 / $357.47 / $357.47
| Professional | | $303.83 | $357.47 | $357.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $401.63 / $401.63 / $401.63
| Facility | | $401.63 | $401.63 | $401.63 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $1,162.00 / $1,162.00 / $1,162.00
| Professional | | $1,162.00 | $1,162.00 | $1,162.00 |