- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.32 / $795.01 / $795.01
| Facility | | $206.32 | $795.01 | $795.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.54 / $187.57 / $187.57
| Professional | | $176.54 | $187.57 | $187.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.10 / $182.10 / $187.57
| Facility | | $182.10 | $182.10 | $187.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.57 / $187.57 / $187.57
| Professional | | $187.57 | $187.57 | $187.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,053.86 / $4,053.86 / $4,053.86
| Facility | | $4,053.86 | $4,053.86 | $4,053.86 |