- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.83 / $502.83 / $502.83
| Facility | | $502.83 | $502.83 | $502.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.78 / $350.07 / $560.11
| Professional | | $204.78 | $350.07 | $560.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $422.22 / $444.44 / $472.77
| Facility | | $422.22 | $444.44 | $472.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.55 / $475.55 / $475.55
| Professional | | $475.55 | $475.55 | $475.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $528.47 / $528.47 / $528.47
| Facility | | $528.47 | $528.47 | $528.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.78 / $528.47 / $1,110.47
| Professional | | $385.78 | $528.47 | $1,110.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.78 / $538.94 / $3,410.50
| Facility | | $204.78 | $538.94 | $3,410.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.47 / $382.90 / $854.34
| Professional | | $211.47 | $382.90 | $854.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.41 / $333.62 / $488.80
| Professional | | $222.41 | $333.62 | $488.80 |