- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $208.93 / $478.63
| Professional | | $158.49 | $208.93 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $489.78 / $645.65
| Professional | | $323.59 | $489.78 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $295.12 / $389.05
| Professional | | $208.93 | $295.12 | $389.05 |
- 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
- $204.17 / $371.54 / $630.96
| Professional | | $204.17 | $371.54 | $630.96 |