- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.56 / $402.40 / $516.63
| Professional | | $370.56 | $402.40 | $516.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.00 / $252.00 / $252.00
| Facility | | $252.00 | $252.00 | $252.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.00 / $776.00 / $1,174.00
| Professional | | $716.00 | $776.00 | $1,174.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.13 / $741.13 / $1,136.89
| Professional | | $473.13 | $741.13 | $1,136.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $538.78 / $773.85 / $1,202.88
| Professional | | $538.78 | $773.85 | $1,202.88 |