- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $1,202.26 / $1,202.26
| Facility | | $478.63 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $489.78 / $512.86
| Professional | | $478.63 | $489.78 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $870.96 / $1,698.24
| Facility | | $660.69 | $870.96 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $562.34
| Professional | | $501.19 | $501.19 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41,686.94 / $41,686.94 / $63,095.73
| Facility | | $41,686.94 | $41,686.94 | $63,095.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Professional | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Professional | | $501.19 | $501.19 | $501.19 |