- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $697.97
| Professional | | $500.00 | $500.00 | $697.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,921.75 / $1,921.75 / $1,935.17
| Facility | | $1,921.75 | $1,921.75 | $1,935.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,299.68 / $1,299.68 / $1,299.68
| Facility | | $1,299.68 | $1,299.68 | $1,299.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.30 / $520.38 / $899.76
| Professional | | $416.30 | $520.38 | $899.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,299.68 / $1,299.68 / $1,299.68
| Facility | | $1,299.68 | $1,299.68 | $1,299.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.30 / $520.38 / $899.76
| Professional | | $416.30 | $520.38 | $899.76 |