- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $295.12
| Facility | | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,344.23 / $3,162.28
| Facility | | $1,995.26 | $2,344.23 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $12,589.25 / $20,417.38
| Facility | | $9,549.93 | $12,589.25 | $20,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $8,912.51 / $11,481.54
| Facility | | $5,495.41 | $8,912.51 | $11,481.54 |