- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.29 / $605.00 / $763.67
| Professional | | $517.29 | $605.00 | $763.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.61 / $529.79 / $871.98
| Facility | | $141.61 | $529.79 | $871.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.80 / $190.40 / $238.00
| Professional | | $142.80 | $190.40 | $238.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.54 / $297.02 / $459.95
| Facility | | $219.54 | $297.02 | $459.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $620.76 / $660.00 / $1,380.97
| Facility | | $620.76 | $660.00 | $1,380.97 |