- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.83 / $362.28 / $525.89
| Professional | | $267.83 | $362.28 | $525.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $216.14 / $350.55 / $492.85
| Facility | | $216.14 | $350.55 | $492.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.00 / $1,122.00 / $8,263.84
| Professional | | $1,122.00 | $1,122.00 | $8,263.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.31 / $292.31 / $292.31
| Facility | | $292.31 | $292.31 | $292.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.55 / $299.00 / $369.46
| Professional | | $225.55 | $299.00 | $369.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.18 / $308.88 / $318.55
| Professional | | $200.18 | $308.88 | $318.55 |