- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.17 / $790.19 / $836.22
| Professional | | $586.17 | $790.19 | $836.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.84 / $1,005.69 / $1,005.69
| Professional | | $854.84 | $1,005.69 | $1,005.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.00 / $504.00 / $504.00
| Facility | | $504.00 | $504.00 | $504.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.40 / $504.00 / $504.00
| Professional | | $428.40 | $504.00 | $504.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.00 / $1,120.31 / $1,868.75
| Professional | | $897.00 | $1,120.31 | $1,868.75 |