- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $594.40 / $594.40 / $1,052.08
| Facility | | $594.40 | $594.40 | $1,052.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.40 / $1,052.08 / $1,052.08
| Professional | | $594.40 | $1,052.08 | $1,052.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.71 / $456.71 / $608.10
| Professional | | $456.71 | $456.71 | $608.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.07 / $600.07 / $1,170.14
| Professional | | $600.07 | $600.07 | $1,170.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.61 / $1,056.61 / $1,056.61
| Professional | | $1,056.61 | $1,056.61 | $1,056.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $594.40 / $1,052.08 / $1,662.29
| Facility | | $594.40 | $1,052.08 | $1,662.29 |