- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $721.66 / $721.66 / $1,649.50
| Facility | | $721.66 | $721.66 | $1,649.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $157.21 / $264.54
| Professional | | $151.16 | $157.21 | $264.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $151.16
| Professional | | $151.16 | $151.16 | $151.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $151.16
| Facility | | $151.16 | $151.16 | $151.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $151.16
| Professional | | $151.16 | $151.16 | $151.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $151.16
| Professional | | $151.16 | $151.16 | $151.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $721.66 / $1,649.50 / $3,089.26
| Facility | | $721.66 | $1,649.50 | $3,089.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $157.21 / $306.55
| Professional | | $151.16 | $157.21 | $306.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $219.20
| Professional | | $151.16 | $151.16 | $219.20 |