- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.35 / $2,597.27 / $2,597.27
| Professional | | $593.35 | $2,597.27 | $2,597.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $765.04 / $765.04 / $765.04
| Facility | | $765.04 | $765.04 | $765.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.46 / $495.06 / $807.23
| Professional | | $485.46 | $495.06 | $807.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $462.62 / $765.04 / $980.00
| Facility | | $462.62 | $765.04 | $980.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.37 / $650.79 / $906.73
| Professional | | $459.37 | $650.79 | $906.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,490.00 / $1,490.00 / $1,490.00
| Facility | | $1,490.00 | $1,490.00 | $1,490.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $722.81 / $806.21 / $931.31
| Professional | | $722.81 | $806.21 | $931.31 |