- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.14 / $265.17 / $450.97
| Professional | | $212.14 | $265.17 | $450.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.21 / $1,022.73 / $1,022.73
| Facility | | $645.21 | $1,022.73 | $1,022.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.74 / $1,577.03 / $1,577.03
| Professional | | $1,462.74 | $1,577.03 | $1,577.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.36 / $373.83 / $487.84
| Facility | | $184.36 | $373.83 | $487.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.00 / $395.00 / $395.00
| Professional | | $395.00 | $395.00 | $395.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.36 / $373.83 / $487.84
| Facility | | $184.36 | $373.83 | $487.84 |