- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $190.55 / $323.59
| Professional | | $120.23 | $190.55 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $512.86 / $691.83
| Professional | | $257.04 | $512.86 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $257.04 / $416.87
| Professional | | $158.49 | $257.04 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,288.25 / $5,370.32
| Facility | | $1,258.93 | $1,288.25 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $363.08 / $630.96
| Professional | | $181.97 | $363.08 | $630.96 |