- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.40 / $503.40 / $1,069.72
| Facility | | $503.40 | $503.40 | $1,069.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.75 / $407.75 / $407.75
| Professional | | $407.75 | $407.75 | $407.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $487.14 / $611.48 / $1,740.25
| Facility | | $487.14 | $611.48 | $1,740.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.36 / $327.20 / $327.20
| Professional | | $201.36 | $327.20 | $327.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,073.74 / $1,073.74 / $1,073.74
| Facility | | $1,073.74 | $1,073.74 | $1,073.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.00 / $525.00 / $656.25
| Professional | | $525.00 | $525.00 | $656.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.40 / $503.40 / $609.62
| Professional | | $503.40 | $503.40 | $609.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.40 / $503.40 / $815.51
| Facility | | $503.40 | $503.40 | $815.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.75 / $407.75 / $503.40
| Professional | | $407.75 | $407.75 | $503.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.04 / $302.04 / $729.93
| Professional | | $302.04 | $302.04 | $729.93 |