- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $422.63 / $493.87 / $796.60
| Facility | | $422.63 | $493.87 | $796.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.15 / $267.10 / $303.52
| Professional | | $181.15 | $267.10 | $303.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.97 / $1,434.97 / $1,434.97
| Professional | | $1,434.97 | $1,434.97 | $1,434.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.40 / $58.40 / $58.40
| Professional | | $58.40 | $58.40 | $58.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,243.40 / $20,243.40 / $20,243.40
| Facility | | $20,243.40 | $20,243.40 | $20,243.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.36 / $840.36 / $1,434.97
| Professional | | $840.36 | $840.36 | $1,434.97 |