- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $954.99 / $7,413.10
| Facility | | $389.05 | $954.99 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $707.95
| Professional | | $575.44 | $575.44 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $426.58 / $676.08
| Facility | | $269.15 | $426.58 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $2,137.96 / $4,265.80
| Facility | | $776.25 | $2,137.96 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $28,840.32
| Facility | | $2,137.96 | $2,137.96 | $28,840.32 |