- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.60 / $630.64 / $788.31
| Professional | | $412.60 | $630.64 | $788.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $298.42 / $439.09 / $630.02
| Facility | | $298.42 | $439.09 | $630.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.00 / $2,052.00 / $2,052.00
| Professional | | $2,052.00 | $2,052.00 | $2,052.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $521.00 / $521.00 / $521.00
| Facility | | $521.00 | $521.00 | $521.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.00 / $502.00 / $540.80
| Professional | | $421.00 | $502.00 | $540.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.48 / $324.48 / $324.48
| Professional | | $324.48 | $324.48 | $324.48 |