- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $562.34 / $776.25
| Professional | | $446.68 | $562.34 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Facility | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $616.60 / $812.83
| Professional | | $524.81 | $616.60 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $630.96 / $707.95
| Professional | | $575.44 | $630.96 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.29 / $257.04 / $426.58
| Facility | | $51.29 | $257.04 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $426.58 / $758.58
| Professional | | $338.84 | $426.58 | $758.58 |