- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $275.42 / $478.63
| Professional | | $245.47 | $275.42 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $812.83 / $812.83
| Professional | | $537.03 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $478.63 / $794.33
| Professional | | $281.84 | $478.63 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $295.12 / $3,090.30
| Facility | | $204.17 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $478.63 / $977.24
| Professional | | $275.42 | $478.63 | $977.24 |