- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,445.44 / $1,445.44
| Facility | | $1,348.96 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $602.56
| Professional | | $575.44 | $575.44 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $660.69 / $1,819.70
| Facility | | $562.34 | $660.69 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $575.44
| Professional | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $602.56
| Facility | | $575.44 | $575.44 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $575.44
| Professional | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $724.44
| Professional | | $602.56 | $602.56 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,445.44
| Facility | | $1,348.96 | $1,348.96 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $1,445.44
| Professional | | $575.44 | $602.56 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $575.44 / $870.96
| Professional | | $489.78 | $575.44 | $870.96 |