- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.37 / $441.37 / $551.72
| Professional | | $441.37 | $441.37 | $551.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.55 / $311.64 / $770.25
| Facility | | $301.55 | $311.64 | $770.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.00 / $1,141.00 / $1,141.00
| Professional | | $308.00 | $1,141.00 | $1,141.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.00 / $385.00 / $385.00
| Facility | | $385.00 | $385.00 | $385.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.00 / $385.00 / $402.76
| Professional | | $308.00 | $385.00 | $402.76 |