- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.38 / $426.38 / $532.97
| Professional | | $426.38 | $426.38 | $532.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $729.24 / $934.28 / $1,002.00
| Facility | | $729.24 | $934.28 | $1,002.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.90 / $842.79 / $1,002.00
| Professional | | $445.90 | $842.79 | $1,002.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,002.00 / $1,002.00 / $1,002.00
| Facility | | $1,002.00 | $1,002.00 | $1,002.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.90 / $769.23 / $1,002.00
| Professional | | $445.90 | $769.23 | $1,002.00 |