- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.48 / $776.48 / $970.59
| Professional | | $776.48 | $776.48 | $970.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,616.95 / $3,616.95 / $3,616.95
| Facility | | $3,616.95 | $3,616.95 | $3,616.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.00 / $1,820.00 / $1,820.00
| Professional | | $571.00 | $1,820.00 | $1,820.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $421.68 / $421.68 / $790.28
| Facility | | $421.68 | $421.68 | $790.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.68 / $694.92 / $790.28
| Professional | | $421.68 | $694.92 | $790.28 |