- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $575.44 / $707.95
| Professional | | $389.05 | $575.44 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.11 / $85.11 / $85.11
| Facility | | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $1,071.52
| Professional | | $645.65 | $645.65 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $645.65 / $977.24
| Facility | | $104.71 | $645.65 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.48 / $288.40 / $489.78
| Facility | | $35.48 | $288.40 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $371.54 / $549.54
| Professional | | $288.40 | $371.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $4,265.80 / $4,265.80
| Facility | | $100.00 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,606.93 / $6,606.93
| Professional | | $3,981.07 | $6,606.93 | $6,606.93 |