- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.50 / $955.58 / $955.58
| Professional | | $713.50 | $955.58 | $955.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.44 / $1,042.44 / $1,042.44
| Facility | | $1,042.44 | $1,042.44 | $1,042.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.07 / $886.07 / $886.07
| Professional | | $886.07 | $886.07 | $886.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.44 / $1,042.44 / $1,042.44
| Facility | | $1,042.44 | $1,042.44 | $1,042.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.90 / $800.22 / $1,199.76
| Professional | | $479.90 | $800.22 | $1,199.76 |