- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.67 / $285.67 / $285.67
| Facility | | $285.67 | $285.67 | $285.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.97 / $285.67 / $384.15
| Professional | | $255.97 | $285.67 | $384.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.13 / $573.17 / $1,040.67
| Facility | | $510.13 | $573.17 | $1,040.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.66 / $307.66 / $331.81
| Professional | | $307.66 | $307.66 | $331.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $361.45 / $361.45 / $361.45
| Facility | | $361.45 | $361.45 | $361.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.86 / $263.86 / $545.86
| Professional | | $263.86 | $263.86 | $545.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.30 / $285.67 / $641.77
| Facility | | $164.30 | $285.67 | $641.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.30 / $164.30 / $164.30
| Professional | | $164.30 | $164.30 | $164.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.39 / $637.66 / $1,010.06
| Professional | | $372.39 | $637.66 | $1,010.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.09 / $254.50 / $383.37
| Professional | | $231.09 | $254.50 | $383.37 |