- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $194.98 / $501.19
| Professional | | $177.83 | $194.98 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $575.44 / $691.83
| Professional | | $380.19 | $575.44 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $338.84 / $426.58
| Professional | | $245.47 | $338.84 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $10,471.29
| Facility | | $2,630.27 | $2,754.23 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $398.11 / $676.08
| Professional | | $218.78 | $398.11 | $676.08 |