- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $177.83 / $416.87
| Professional | | $158.49 | $177.83 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $407.38 / $467.74
| Professional | | $323.59 | $407.38 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $281.84 / $380.19
| Professional | | $223.87 | $281.84 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,630.27 / $10,471.29
| Facility | | $1,737.80 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $371.54 / $660.69
| Professional | | $213.80 | $371.54 | $660.69 |