- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.00 / $381.62 / $1,964.01
| Professional | | $330.00 | $381.62 | $1,964.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $596.78 / $596.78 / $596.78
| Facility | | $596.78 | $596.78 | $596.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.37 / $596.78 / $1,104.51
| Professional | | $373.37 | $596.78 | $1,104.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $368.12 / $556.74 / $704.61
| Facility | | $368.12 | $556.74 | $704.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.17 / $613.07 / $1,021.59
| Professional | | $398.17 | $613.07 | $1,021.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.76 / $661.38 / $784.69
| Professional | | $534.76 | $661.38 | $784.69 |