- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $208.93 / $380.19
| Professional | | $181.97 | $208.93 | $380.19 |
- 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
- $380.19 / $575.44 / $630.96
| Professional | | $380.19 | $575.44 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $371.54 / $616.60
| Professional | | $229.09 | $371.54 | $616.60 |
- 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
- $208.93 / $380.19 / $741.31
| Professional | | $208.93 | $380.19 | $741.31 |