- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $251.19 / $338.84
| Professional | | $165.96 | $251.19 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $812.83 / $1,258.93
| Professional | | $478.63 | $812.83 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $363.08 / $676.08
| Professional | | $199.53 | $363.08 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $295.12 / $3,090.30
| Facility | | $199.53 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $371.54 / $691.83
| Professional | | $223.87 | $371.54 | $691.83 |