- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,255.50 / $5,255.50 / $5,255.50
| Facility | | $5,255.50 | $5,255.50 | $5,255.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.07 / $719.07 / $749.48
| Professional | | $719.07 | $719.07 | $749.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $685.50 / $1,076.51 / $1,124.22
| Facility | | $685.50 | $1,076.51 | $1,124.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.67 / $685.50 / $685.50
| Professional | | $582.67 | $685.50 | $685.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.89 / $2,425.89 / $2,425.89
| Facility | | $2,425.89 | $2,425.89 | $2,425.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.69 / $1,050.26 / $1,312.82
| Professional | | $534.69 | $1,050.26 | $1,312.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.88 / $548.40 / $1,318.26
| Professional | | $383.88 | $548.40 | $1,318.26 |