- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.76 / $526.16 / $657.71
| Professional | | $306.76 | $526.16 | $657.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $615.17 / $615.17 / $977.07
| Facility | | $615.17 | $615.17 | $977.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.90 / $615.17 / $1,161.00
| Professional | | $522.90 | $615.17 | $1,161.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.17 / $645.10 / $4,704.66
| Facility | | $274.17 | $645.10 | $4,704.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.88 / $478.78 / $666.43
| Professional | | $287.88 | $478.78 | $666.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.91 / $451.57 / $609.26
| Professional | | $353.91 | $451.57 | $609.26 |