- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.06 / $573.46 / $795.16
| Professional | | $465.06 | $573.46 | $795.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.66 / $413.66 / $413.66
| Professional | | $413.66 | $413.66 | $413.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $795.16 / $819.01 / $3,773.67
| Facility | | $795.16 | $819.01 | $3,773.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.96 / $583.25 / $590.10
| Professional | | $576.96 | $583.25 | $590.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.96 / $583.25 / $590.10
| Professional | | $576.96 | $583.25 | $590.10 |