- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.70 / $897.70 / $1,582.30
| Professional | | $897.70 | $897.70 | $1,582.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.10 / $1,743.10 / $1,743.10
| Professional | | $1,743.10 | $1,743.10 | $1,743.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.00 / $504.00 / $1,803.27
| Facility | | $504.00 | $504.00 | $1,803.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.00 / $504.00 / $504.00
| Professional | | $504.00 | $504.00 | $504.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.00 / $1,194.70 / $1,991.17
| Professional | | $897.00 | $1,194.70 | $1,991.17 |