- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $407.38 / $407.38
| Facility | | $371.54 | $407.38 | $407.38 |
- 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
- $933.25 / $1,513.56 / $2,089.30
| Facility | | $933.25 | $1,513.56 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $63.10 / $173.78
| Professional | | $47.86 | $63.10 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $23,988.33 / $48,977.88
| Facility | | $7,585.78 | $23,988.33 | $48,977.88 |