- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.62 / $4,344.99 / $5,259.48
| Facility | | $461.62 | $4,344.99 | $5,259.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.62 / $461.62 / $461.62
| Professional | | $461.62 | $461.62 | $461.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.72 / $479.72 / $479.72
| Professional | | $479.72 | $479.72 | $479.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.88 / $506.88 / $506.88
| Professional | | $506.88 | $506.88 | $506.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.24 / $236.50 / $488.77
| Professional | | $164.24 | $236.50 | $488.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.04 / $543.08 / $543.08
| Professional | | $448.04 | $543.08 | $543.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.72 / $479.72 / $479.72
| Professional | | $479.72 | $479.72 | $479.72 |