- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.76 / $477.20 / $784.94
| Professional | | $381.76 | $477.20 | $784.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $394.66 / $476.56 / $598.07
| Facility | | $394.66 | $476.56 | $598.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.00 / $1,608.00 / $1,633.00
| Professional | | $389.00 | $1,608.00 | $1,633.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.00 / $437.00 / $437.00
| Facility | | $437.00 | $437.00 | $437.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.23 / $400.00 / $575.86
| Professional | | $347.23 | $400.00 | $575.86 |