- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $346.74 / $407.38
| Professional | | $251.19 | $346.74 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Professional | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $660.69 / $676.08
| Facility | | $645.65 | $660.69 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $660.69 / $676.08
| Professional | | $645.65 | $660.69 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $295.12 / $602.56
| Facility | | $275.42 | $295.12 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $602.56 / $741.31
| Professional | | $79.43 | $602.56 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $602.56 / $1,000.00
| Professional | | $512.86 | $602.56 | $1,000.00 |