- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $269.15 / $707.95
| Professional | | $269.15 | $269.15 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $707.95 / $831.76
| Professional | | $562.34 | $707.95 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $478.63 / $676.08
| Professional | | $398.11 | $478.63 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,951.21 / $10,471.29
| Facility | | $2,630.27 | $2,951.21 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $549.54 / $1,096.48
| Professional | | $363.08 | $549.54 | $1,096.48 |