- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $489.78 / $1,380.38
| Professional | | $323.59 | $489.78 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,174.90 / $1,348.96
| Professional | | $1,047.13 | $1,174.90 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $181.97 / $229.09
| Professional | | $181.97 | $181.97 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $1,737.80 / $1,737.80
| Professional | | $416.87 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $323.59 / $323.59
| Facility | | $263.03 | $323.59 | $323.59 |