- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $12,022.64 / $16,595.87
| Facility | | $9,772.37 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $933.25
| Facility | | $660.69 | $660.69 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $660.69 / $691.83
| Professional | | $60.26 | $660.69 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $891.25 / $933.25
| Facility | | $660.69 | $891.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |