- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $371.54 / $371.54
| Facility | | $295.12 | $371.54 | $371.54 |
- 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
- $9,549.93 / $12,589.25 / $30,902.95
| Facility | | $9,549.93 | $12,589.25 | $30,902.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $467.74 / $8,511.38
| Facility | | $371.54 | $467.74 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Professional | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,754.40 / $6,165.95
| Facility | | $5,623.41 | $5,754.40 | $6,165.95 |