- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.50 / $266.50 / $266.50
| Professional | | $266.50 | $266.50 | $266.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $759.21 / $759.21 / $759.21
| Facility | | $759.21 | $759.21 | $759.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.74 / $691.32 / $864.14
| Professional | | $441.74 | $691.32 | $864.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $359.33 / $431.09 / $1,808.42
| Facility | | $359.33 | $431.09 | $1,808.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.17 / $342.65 / $571.08
| Professional | | $194.17 | $342.65 | $571.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $456.86 / $696.24 / $829.67
| Facility | | $456.86 | $696.24 | $829.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.25 / $829.67 / $993.68
| Professional | | $457.25 | $829.67 | $993.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.72 / $917.27 / $1,045.91
| Professional | | $380.72 | $917.27 | $1,045.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.90 / $228.43 / $456.86
| Professional | | $159.90 | $228.43 | $456.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.72 / $380.72 / $380.72
| Professional | | $380.72 | $380.72 | $380.72 |