- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $257.04 / $616.60
| Professional | | $169.82 | $257.04 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $912.01 / $2,137.96
| Professional | | $489.78 | $912.01 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $346.74 / $812.83
| Professional | | $190.55 | $346.74 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $5,370.32
| Facility | | $1,288.25 | $1,621.81 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $323.59 / $724.44
| Professional | | $204.17 | $323.59 | $724.44 |