- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.53 / $589.53 / $736.92
| Professional | | $589.53 | $589.53 | $736.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $439.02 / $453.27 / $987.09
| Facility | | $439.02 | $453.27 | $987.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.00 / $1,658.00 / $1,658.00
| Professional | | $447.00 | $1,658.00 | $1,658.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.00 / $542.00 / $542.00
| Facility | | $542.00 | $542.00 | $542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.00 / $534.00 / $540.08
| Professional | | $447.00 | $534.00 | $540.08 |