- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.08 / $228.47 / $228.47
| Facility | | $224.08 | $228.47 | $228.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.08 / $250.44 / $392.50
| Professional | | $224.08 | $250.44 | $392.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.52 / $395.52 / $395.52
| Professional | | $395.52 | $395.52 | $395.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.20 / $474.62 / $474.62
| Professional | | $314.20 | $474.62 | $474.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.89 / $329.53 / $329.53
| Facility | | $281.89 | $329.53 | $329.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.56 / $240.56 / $329.53
| Professional | | $240.56 | $240.56 | $329.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $711.94 / $2,777.21 / $2,777.21
| Facility | | $711.94 | $2,777.21 | $2,777.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,480.59 / $3,480.59 / $5,273.63
| Professional | | $3,480.59 | $3,480.59 | $5,273.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.40 / $263.08 / $405.42
| Professional | | $175.40 | $263.08 | $405.42 |