- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.22 / $746.22 / $932.78
| Professional | | $746.22 | $746.22 | $932.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $574.00 / $574.00 / $574.00
| Facility | | $574.00 | $574.00 | $574.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.00 / $624.02 / $1,703.26
| Professional | | $525.00 | $624.02 | $1,703.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $399.06 / $574.00 / $657.66
| Facility | | $399.06 | $574.00 | $657.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.06 / $585.00 / $672.09
| Professional | | $399.06 | $585.00 | $672.09 |