- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $229.09 / $281.84
| Professional | | $131.83 | $229.09 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $288.40
| Facility | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $501.19 / $776.25
| Professional | | $275.42 | $501.19 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $338.84 / $602.56
| Professional | | $194.98 | $338.84 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $295.12 / $3,090.30
| Facility | | $229.09 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $346.74 / $776.25
| Professional | | $169.82 | $346.74 | $776.25 |