- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $251.19 / $501.19
| Professional | | $114.82 | $251.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $741.31 / $1,412.54
| Professional | | $457.09 | $741.31 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $263.03 / $549.54
| Professional | | $173.78 | $263.03 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,288.25 / $5,370.32
| Facility | | $831.76 | $1,288.25 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $398.11 / $891.25
| Professional | | $208.93 | $398.11 | $891.25 |