- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.61 / $507.61 / $507.61
| Facility | | $507.61 | $507.61 | $507.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.30 / $438.30 / $507.61
| Professional | | $438.30 | $438.30 | $507.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.36 / $771.32 / $790.50
| Professional | | $652.36 | $771.32 | $790.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.75 / $612.82 / $770.57
| Professional | | $606.75 | $612.82 | $770.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.29 / $507.61 / $2,725.44
| Facility | | $267.29 | $507.61 | $2,725.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.55 / $391.59 / $555.91
| Professional | | $217.55 | $391.59 | $555.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.04 / $391.59 / $555.91
| Professional | | $174.04 | $391.59 | $555.91 |