- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.65 / $710.65 / $710.65
| Professional | | $710.65 | $710.65 | $710.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $802.11 / $1,086.21 / $1,655.39
| Facility | | $802.11 | $1,086.21 | $1,655.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.00 / $4.00 / $1,841.90
| Professional | | $4.00 | $4.00 | $1,841.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,358.31 / $1,929.70 / $16,394.00
| Facility | | $1,358.31 | $1,929.70 | $16,394.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,225.29 / $3,225.29 / $3,225.29
| Professional | | $3,225.29 | $3,225.29 | $3,225.29 |