- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.20 / $496.20 / $496.20
| Facility | | $496.20 | $496.20 | $496.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.67 / $411.74 / $496.20
| Professional | | $353.67 | $411.74 | $496.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.37 / $958.96 / $1,198.70
| Professional | | $758.37 | $958.96 | $1,198.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $498.20 / $597.70 / $969.06
| Facility | | $498.20 | $597.70 | $969.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.20 / $316.72 / $1,038.84
| Professional | | $269.20 | $316.72 | $1,038.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $633.44 / $686.23 / $1,156.88
| Facility | | $633.44 | $686.23 | $1,156.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.44 / $802.36 / $1,087.41
| Professional | | $633.44 | $802.36 | $1,087.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.85 / $1,271.80 / $1,450.16
| Professional | | $754.85 | $1,271.80 | $1,450.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.71 / $269.20 / $527.87
| Professional | | $221.71 | $269.20 | $527.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.87 / $527.87 / $527.87
| Professional | | $527.87 | $527.87 | $527.87 |