- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.77 / $368.46 / $368.46
| Facility | | $294.77 | $368.46 | $368.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.46 / $368.46 / $368.46
| Professional | | $368.46 | $368.46 | $368.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,759.18 / $13,034.29 / $20,527.95
| Facility | | $3,759.18 | $13,034.29 | $20,527.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,007.45 / $19,978.64 / $31,882.42
| Facility | | $14,007.45 | $19,978.64 | $31,882.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,401.58 / $12,173.72 / $21,346.87
| Facility | | $8,401.58 | $12,173.72 | $21,346.87 |