- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $371.54 / $371.54
| Facility | | $239.88 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $380.19
| Professional | | $371.54 | $371.54 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $14,791.08 / $34,673.69
| Facility | | $1,122.02 | $14,791.08 | $34,673.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $295.12 / $295.12
| Professional | | $234.42 | $295.12 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $616.60 / $19,952.62
| Facility | | $371.54 | $616.60 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,620.87 / $19,054.61 / $25,703.96
| Facility | | $18,620.87 | $19,054.61 | $25,703.96 |