- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $9,120.11 / $16,595.87
| Facility | | $6,165.95 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $575.44
| Facility | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Professional | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,691.53 / $3,630.78
| Facility | | $2,089.30 | $2,691.53 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $10,964.78 / $16,982.44
| Facility | | $1,995.26 | $10,964.78 | $16,982.44 |