- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.13 / $519.13 / $519.13
| Professional | | $519.13 | $519.13 | $519.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,337.58 / $10,490.12 / $12,538.72
| Facility | | $6,337.58 | $10,490.12 | $12,538.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $680.00 / $680.00
| Facility | | $680.00 | $680.00 | $680.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $5,979.00 / $12,680.00
| Facility | | $3,219.00 | $5,979.00 | $12,680.00 |