- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $891.25 / $1,047.13
| Professional | | $758.58 | $891.25 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $120.23 / $131.83
| Professional | | $109.65 | $120.23 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $173.78 / $2,630.27
| Professional | | $131.83 | $173.78 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.54 / $117.49 / $1,174.90
| Facility | | $57.54 | $117.49 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $120.23 / $165.96
| Professional | | $70.79 | $120.23 | $165.96 |