- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.74 / $302.74 / $302.74
| Facility | | $302.74 | $302.74 | $302.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.74 / $302.74 / $381.54
| Professional | | $211.74 | $302.74 | $381.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.61 / $607.42 / $1,102.83
| Facility | | $540.61 | $607.42 | $1,102.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.64 / $289.64 / $298.33
| Professional | | $289.64 | $289.64 | $298.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.62 / $297.62 / $297.62
| Facility | | $297.62 | $297.62 | $297.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.26 / $217.26 / $509.66
| Professional | | $217.26 | $217.26 | $509.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.41 / $302.74 / $675.76
| Facility | | $153.41 | $302.74 | $675.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.41 / $153.41 / $153.41
| Professional | | $153.41 | $153.41 | $153.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.65 / $621.70 / $1,070.41
| Professional | | $394.65 | $621.70 | $1,070.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.76 / $237.62 / $357.94
| Professional | | $215.76 | $237.62 | $357.94 |