- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.97 / $894.60 / $1,162.70
| Professional | | $809.97 | $894.60 | $1,162.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.43 / $157.43 / $157.43
| Facility | | $157.43 | $157.43 | $157.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.55 / $116.55 / $116.55
| Professional | | $116.55 | $116.55 | $116.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.05 / $124.05 / $1,223.23
| Professional | | $124.05 | $124.05 | $1,223.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.41 / $615.51 / $984.71
| Professional | | $492.41 | $615.51 | $984.71 |