- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $269.15 / $602.56
| Professional | | $177.83 | $269.15 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $467.74 / $630.96
| Professional | | $323.59 | $467.74 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $309.03 / $489.78
| Professional | | $213.80 | $309.03 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,380.38 / $5,370.32
| Facility | | $1,288.25 | $1,380.38 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $331.13 / $724.44
| Professional | | $208.93 | $331.13 | $724.44 |