- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $6,760.83
| Facility | | $5,495.41 | $5,495.41 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,481.54 / $11,481.54 / $11,481.54
| Professional | | $11,481.54 | $11,481.54 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $323.59 / $323.59
| Facility | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,466.84 / $4,786.30
| Facility | | $4,168.69 | $4,466.84 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,754.40 / $10,232.93
| Facility | | $1,737.80 | $5,754.40 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $11.48 / $11.48
| Professional | | $11.48 | $11.48 | $11.48 |