- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $495.96 / $1,148.40 / $2,400.80
| Facility | | $495.96 | $1,148.40 | $2,400.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.78 / $416.83 / $563.34
| Professional | | $416.78 | $416.83 | $563.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,625.46 / $1,625.46 / $1,625.46
| Facility | | $1,625.46 | $1,625.46 | $1,625.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.78 / $458.46 / $625.16
| Facility | | $416.78 | $458.46 | $625.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.78 / $416.78 / $500.14
| Professional | | $416.78 | $416.78 | $500.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $812.72
| Professional | | $30.00 | $30.00 | $812.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $625.16 / $896.08 / $1,500.41
| Facility | | $625.16 | $896.08 | $1,500.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.87 / $622.87 / $643.78
| Professional | | $622.87 | $622.87 | $643.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.11 / $175.07 / $497.41
| Professional | | $165.11 | $175.07 | $497.41 |