- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $229.09 / $588.84
| Professional | | $177.83 | $229.09 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $407.38 / $457.09
| Professional | | $346.74 | $407.38 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $371.54 / $489.78
| Professional | | $269.15 | $371.54 | $489.78 |
- 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
- $251.19 / $446.68 / $741.31
| Professional | | $251.19 | $446.68 | $741.31 |