- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $234.42 / $501.19
| Professional | | $138.04 | $234.42 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $389.05 / $478.63
| Professional | | $275.42 | $389.05 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $295.12 / $426.58
| Professional | | $165.96 | $295.12 | $426.58 |
- 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
- $162.18 / $371.54 / $549.54
| Professional | | $162.18 | $371.54 | $549.54 |