- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.83 / $362.28 / $525.89
| Professional | | $289.83 | $362.28 | $525.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.63 / $309.02 / $432.98
| Facility | | $188.63 | $309.02 | $432.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.10 / $479.76 / $8,263.84
| Professional | | $244.10 | $479.76 | $8,263.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.55 / $318.00 / $318.00
| Facility | | $225.55 | $318.00 | $318.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.55 / $318.00 / $369.46
| Professional | | $225.55 | $318.00 | $369.46 |