- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.70 / $239.63 / $254.63
| Professional | | $203.70 | $239.63 | $254.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.21 / $214.81 / $310.18
| Facility | | $25.21 | $214.81 | $310.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.21 / $203.59 / $271.41
| Professional | | $25.21 | $203.59 | $271.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.16 / $238.16 / $418.93
| Facility | | $238.16 | $238.16 | $418.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.16 / $238.16 / $1,732.69
| Professional | | $238.16 | $238.16 | $1,732.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.22 / $193.43 / $291.38
| Professional | | $136.22 | $193.43 | $291.38 |