- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.06 / $971.06 / $971.06
| Professional | | $971.06 | $971.06 | $971.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $611.41 / $611.41 / $611.41
| Professional | | $611.41 | $611.41 | $611.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.62 / $1,388.62 / $1,388.62
| Facility | | $1,388.62 | $1,388.62 | $1,388.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.06 / $507.06 / $724.38
| Professional | | $507.06 | $507.06 | $724.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.62 / $1,388.62 / $1,388.62
| Facility | | $1,388.62 | $1,388.62 | $1,388.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.06 / $611.41 / $724.38
| Professional | | $507.06 | $611.41 | $724.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.34 / $1,025.01 / $1,378.43
| Professional | | $683.34 | $1,025.01 | $1,378.43 |