- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $472.25 / $472.25 / $472.25
| Facility | | $472.25 | $472.25 | $472.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $424.09
| Professional | | $328.34 | $328.34 | $424.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,521.41 / $6,213.56 / $10,437.45
| Facility | | $2,521.41 | $6,213.56 | $10,437.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $752.25
| Facility | | $328.34 | $328.34 | $752.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $328.34
| Professional | | $328.34 | $328.34 | $328.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.74 / $838.46 / $1,257.69
| Professional | | $470.74 | $838.46 | $1,257.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.50 / $331.62 / $678.00
| Facility | | $13.50 | $331.62 | $678.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $505.40
| Professional | | $328.34 | $328.34 | $505.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $348.04
| Professional | | $328.34 | $328.34 | $348.04 |