- 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
- $1,381.08 / $1,381.08 / $1,381.08
| Facility | | $1,381.08 | $1,381.08 | $1,381.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.00 / $1,002.00 / $1,002.00
| Professional | | $1,002.00 | $1,002.00 | $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
- $721.00 / $769.23 / $994.00
| Professional | | $721.00 | $769.23 | $994.00 |