- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $368.46 / $368.46 / $368.46
| Facility | | $368.46 | $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
- $2,785.97 / $3,664.32 / $7,087.97
| Facility | | $2,785.97 | $3,664.32 | $7,087.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.61 / $700.07 / $12,735.25
| Facility | | $331.61 | $700.07 | $12,735.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,351.47 / $3,910.04 / $5,250.63
| Facility | | $3,351.47 | $3,910.04 | $5,250.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.83 / $1,253.83 / $1,253.83
| Professional | | $1,253.83 | $1,253.83 | $1,253.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,516.07 / $9,944.73 / $12,989.87
| Facility | | $9,516.07 | $9,944.73 | $12,989.87 |