- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,504.73 / $1,897.99 / $8,249.83
| Facility | | $1,504.73 | $1,897.99 | $8,249.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.50 / $738.52 / $738.52
| Professional | | $585.50 | $738.52 | $738.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.75 / $727.53 / $1,034.23
| Professional | | $549.75 | $727.53 | $1,034.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,039.07 / $13,039.07 / $13,039.07
| Facility | | $13,039.07 | $13,039.07 | $13,039.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $559.74 / $820.33 / $1,929.20
| Professional | | $559.74 | $820.33 | $1,929.20 |