- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.60 / $575.60 / $575.60
| Facility | | $575.60 | $575.60 | $575.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.48 / $477.75 / $575.60
| Professional | | $460.48 | $477.75 | $575.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.43 / $508.43 / $508.43
| Facility | | $508.43 | $508.43 | $508.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.43 / $508.43 / $508.43
| Professional | | $508.43 | $508.43 | $508.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $488.11 / $508.43 / $707.88
| Facility | | $488.11 | $508.43 | $707.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $2,000.00 / $3,900.00
| Professional | | $30.00 | $2,000.00 | $3,900.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $430.56 / $587.13 / $998.12
| Facility | | $430.56 | $587.13 | $998.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.60 / $575.60 / $610.14
| Professional | | $575.60 | $575.60 | $610.14 |