- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $616.60
| Professional | | $489.78 | $489.78 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $630.96
| Professional | | $151.36 | $151.36 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $457.09 / $776.25
| Facility | | $323.59 | $457.09 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $3,090.30 / $3,090.30
| Professional | | $416.87 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $457.09
| Professional | | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Professional | | $426.58 | $426.58 | $426.58 |