- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $346.74 / $645.65
| Professional | | $309.03 | $346.74 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,023.29 / $1,047.13
| Professional | | $676.08 | $1,023.29 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $616.60 / $1,023.29
| Professional | | $363.08 | $616.60 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $295.12 / $3,090.30
| Facility | | $204.17 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $616.60 / $1,230.27
| Professional | | $346.74 | $616.60 | $1,230.27 |