- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.29 / $777.42 / $991.17
| Professional | | $586.29 | $777.42 | $991.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.00 / $261.00 / $261.00
| Professional | | $261.00 | $261.00 | $261.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.20 / $280.20 / $503.80
| Professional | | $280.20 | $280.20 | $503.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.14 / $403.25 / $403.25
| Facility | | $346.14 | $403.25 | $403.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,204.00 / $1,386.51
| Professional | | $1,204.00 | $1,204.00 | $1,386.51 |