- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.06 / $297.06 / $506.01
| Professional | | $297.06 | $297.06 | $506.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.25 / $593.25 / $741.56
| Professional | | $593.25 | $593.25 | $741.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.07 / $248.45 / $455.49
| Professional | | $238.07 | $248.45 | $455.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.34 / $1,080.34 / $1,227.68
| Professional | | $1,080.34 | $1,080.34 | $1,227.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.45 / $387.71 / $583.57
| Professional | | $248.45 | $387.71 | $583.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $678.00 / $678.00 / $678.00
| Facility | | $678.00 | $678.00 | $678.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.00 / $678.00 / $678.00
| Professional | | $678.00 | $678.00 | $678.00 |