- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.42 / $508.42 / $508.42
| Facility | | $508.42 | $508.42 | $508.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.09 / $508.42 / $634.05
| Professional | | $382.09 | $508.42 | $634.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $907.89 / $1,020.11 / $1,852.10
| Facility | | $907.89 | $1,020.11 | $1,852.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.33 / $505.33 / $545.76
| Professional | | $505.33 | $505.33 | $545.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.34 / $524.34 / $524.34
| Facility | | $524.34 | $524.34 | $524.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.77 / $382.77 / $938.36
| Professional | | $382.77 | $382.77 | $938.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $270.27 / $508.42 / $1,142.16
| Facility | | $270.27 | $508.42 | $1,142.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.27 / $270.27 / $270.27
| Professional | | $270.27 | $270.27 | $270.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.76 / $1,134.85 / $1,797.62
| Professional | | $662.76 | $1,134.85 | $1,797.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.12 / $418.64 / $630.61
| Professional | | $380.12 | $418.64 | $630.61 |