- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $581.25 / $581.25 / $581.25
| Facility | | $581.25 | $581.25 | $581.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.25 / $581.25 / $581.25
| Professional | | $581.25 | $581.25 | $581.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.41 / $630.61 / $663.79
| Professional | | $597.41 | $630.61 | $663.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.74 / $316.74 / $651.90
| Facility | | $316.74 | $316.74 | $651.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.74 / $509.98 / $989.06
| Professional | | $316.74 | $509.98 | $989.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.79 / $581.25 / $3,536.46
| Facility | | $56.79 | $581.25 | $3,536.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.60 / $265.47 / $460.54
| Professional | | $151.60 | $265.47 | $460.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.21 / $88.50 / $158.13
| Facility | | $83.21 | $88.50 | $158.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.50 / $103.41 / $209.17
| Professional | | $88.50 | $103.41 | $209.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.75 / $241.50 / $460.54
| Professional | | $160.75 | $241.50 | $460.54 |