- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.11 / $321.81 / $386.18
| Facility | | $211.11 | $321.81 | $386.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.09 / $211.11 / $218.83
| Professional | | $193.09 | $211.11 | $218.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $283.20 / $386.18 / $450.54
| Facility | | $283.20 | $386.18 | $450.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.94 / $308.94 / $347.56
| Professional | | $308.94 | $308.94 | $347.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.18 / $556.82 / $772.27
| Facility | | $209.18 | $556.82 | $772.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.49 / $482.58 / $1,240.91
| Professional | | $146.49 | $482.58 | $1,240.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,614.75 / $1,614.75 / $1,614.75
| Facility | | $1,614.75 | $1,614.75 | $1,614.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.85 / $148.63 / $477.74
| Professional | | $115.85 | $148.63 | $477.74 |