- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.68 / $432.59 / $840.63
| Facility | | $308.68 | $432.59 | $840.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $311.77
| Professional | | $308.68 | $308.68 | $311.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.20 / $308.68 / $398.05
| Facility | | $291.20 | $308.68 | $398.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $308.68
| Professional | | $308.68 | $308.68 | $308.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.94 / $8,702.00 / $13,785.00
| Facility | | $293.94 | $8,702.00 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.01 / $306.79 / $306.79
| Professional | | $285.01 | $306.79 | $306.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $631.97 / $631.97 / $631.97
| Facility | | $631.97 | $631.97 | $631.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $361.68
| Professional | | $308.68 | $308.68 | $361.68 |