- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $316.23 / $660.69
| Professional | | $213.80 | $316.23 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $501.19 / $602.56
| Professional | | $426.58 | $501.19 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $457.09 / $645.65
| Professional | | $371.54 | $457.09 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $537.03 / $977.24
| Professional | | $331.13 | $537.03 | $977.24 |