- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.15 / $479.15 / $598.92
| Professional | | $479.15 | $479.15 | $598.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $254.26 / $564.26 / $680.17
| Facility | | $254.26 | $564.26 | $680.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.00 / $3,126.00 / $3,126.00
| Professional | | $415.00 | $3,126.00 | $3,126.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.00 / $458.00 / $458.00
| Facility | | $458.00 | $458.00 | $458.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.00 / $428.00 / $460.70
| Professional | | $408.00 | $428.00 | $460.70 |