- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $436.52
| Facility | | $245.47 | $245.47 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $316.23 / $478.63
| Professional | | $245.47 | $316.23 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $457.09
| Professional | | $426.58 | $426.58 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $489.78
| Facility | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $489.78
| Professional | | $363.08 | $363.08 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,265.80 / $4,265.80
| Professional | | $3,467.37 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $380.19 / $436.52
| Facility | | $218.78 | $380.19 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $288.40 / $426.58
| Professional | | $190.55 | $288.40 | $426.58 |