- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.44 / $624.44 / $780.55
| Professional | | $624.44 | $624.44 | $780.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.65 / $1,078.65 / $1,078.65
| Facility | | $1,078.65 | $1,078.65 | $1,078.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.00 / $1,663.45 / $1,663.45
| Professional | | $396.00 | $1,663.45 | $1,663.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.51 / $471.00 / $686.41
| Facility | | $416.51 | $471.00 | $686.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.00 / $543.90 / $724.36
| Professional | | $396.00 | $543.90 | $724.36 |