- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.63 / $554.63 / $693.28
| Professional | | $554.63 | $554.63 | $693.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.47 / $132.28 / $745.02
| Facility | | $128.47 | $132.28 | $745.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.00 / $960.33 / $960.33
| Professional | | $132.00 | $960.33 | $960.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.00 / $268.00 / $268.00
| Facility | | $268.00 | $268.00 | $268.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.00 / $296.54 / $512.62
| Professional | | $132.00 | $296.54 | $512.62 |