- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.89 / $1,058.70 / $1,058.70
| Professional | | $188.89 | $1,058.70 | $1,058.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.58 / $317.58 / $317.58
| Professional | | $317.58 | $317.58 | $317.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.58 / $317.58 / $317.58
| Facility | | $317.58 | $317.58 | $317.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.58 / $317.58 / $355.24
| Professional | | $317.58 | $317.58 | $355.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.41 / $583.04 / $631.24
| Facility | | $156.41 | $583.04 | $631.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.10 / $291.18 / $420.00
| Professional | | $194.10 | $291.18 | $420.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.83 / $375.21 / $583.04
| Professional | | $307.83 | $375.21 | $583.04 |