- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.52 / $383.21 / $486.85
| Professional | | $330.52 | $383.21 | $486.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.00 / $1,712.00 / $1,712.00
| Professional | | $1,712.00 | $1,712.00 | $1,712.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,034.56 / $1,034.56 / $1,034.56
| Facility | | $1,034.56 | $1,034.56 | $1,034.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.93 / $464.79 / $789.46
| Professional | | $364.93 | $464.79 | $789.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.52 / $507.18 / $849.73
| Professional | | $381.52 | $507.18 | $849.73 |