- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.24 / $324.24 / $405.30
| Professional | | $324.24 | $324.24 | $405.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.37 / $688.14 / $780.06
| Facility | | $436.37 | $688.14 | $780.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.00 / $1,577.03 / $1,577.03
| Professional | | $563.00 | $1,577.03 | $1,577.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $563.00 / $563.00 / $563.00
| Facility | | $563.00 | $563.00 | $563.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.00 / $563.00 / $607.33
| Professional | | $360.00 | $563.00 | $607.33 |