- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.01 / $260.01 / $260.01
| Facility | | $260.01 | $260.01 | $260.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.01 / $260.01 / $260.01
| Professional | | $260.01 | $260.01 | $260.01 |
- 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
- $234.01 / $494.02 / $12,735.25
| Facility | | $234.01 | $494.02 | $12,735.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,351.47 / $4,021.76 / $5,384.69
| Facility | | $3,351.47 | $4,021.76 | $5,384.69 |