- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,492.60 / $1,492.60 / $1,492.60
| Facility | | $1,492.60 | $1,492.60 | $1,492.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.95 / $187.57 / $187.57
| Professional | | $180.95 | $187.57 | $187.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.20 / $157.74 / $449.65
| Facility | | $126.20 | $157.74 | $449.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.68 / $163.60 / $163.60
| Professional | | $160.68 | $163.60 | $163.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.40 / $187.57 / $287.08
| Facility | | $161.40 | $187.57 | $287.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.57 / $187.57 / $187.57
| Professional | | $187.57 | $187.57 | $187.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,492.60 / $1,492.60 / $1,492.60
| Facility | | $1,492.60 | $1,492.60 | $1,492.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.57 / $187.57 / $187.57
| Professional | | $187.57 | $187.57 | $187.57 |