- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $977.24
| Facility | | $295.12 | $295.12 | $977.24 |
- 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
- $3,801.89 / $13,182.57 / $19,952.62
| Facility | | $3,801.89 | $13,182.57 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $19,952.62 / $31,622.78
| Facility | | $7,585.78 | $19,952.62 | $31,622.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $11,220.18 / $19,952.62
| Facility | | $5,623.41 | $11,220.18 | $19,952.62 |