- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.18 / $473.18 / $591.47
| Professional | | $473.18 | $473.18 | $591.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.00 / $437.00 / $437.00
| Facility | | $437.00 | $437.00 | $437.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.32 / $474.00 / $1,429.00
| Professional | | $396.32 | $474.00 | $1,429.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.98 / $416.90 / $437.00
| Facility | | $252.98 | $416.90 | $437.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.98 / $437.00 / $522.04
| Professional | | $252.98 | $437.00 | $522.04 |