- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,890.45 / $3,890.45
| Facility | | $1,412.54 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $6,760.83
| Professional | | $3,801.89 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33,113.11 / $33,113.11 / $38,904.51
| Facility | | $33,113.11 | $33,113.11 | $38,904.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $26,302.68
| Facility | | $4,466.84 | $4,466.84 | $26,302.68 |