- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.67 / $564.64 / $1,377.60
| Facility | | $220.67 | $564.64 | $1,377.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.00 / $295.89 / $317.60
| Professional | | $23.00 | $295.89 | $317.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.80 / $5,695.20 / $8,738.06
| Facility | | $310.80 | $5,695.20 | $8,738.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.76 / $116.76 / $116.76
| Professional | | $116.76 | $116.76 | $116.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $313.89 / $384.60 / $666.85
| Facility | | $313.89 | $384.60 | $666.85 |