- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $660.69 / $794.33
| Facility | | $407.38 | $660.69 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $758.58
| Professional | | $660.69 | $660.69 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $812.83 / $1,905.46
| Facility | | $660.69 | $812.83 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $660.69 / $1,737.80
| Professional | | $125.89 | $660.69 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $660.69 / $2,238.72
| Facility | | $616.60 | $660.69 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $1,071.52
| Professional | | $660.69 | $660.69 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,380.38 / $1,819.70
| Facility | | $933.25 | $1,380.38 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $933.25 / $1,737.80
| Professional | | $125.89 | $933.25 | $1,737.80 |