- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $16,982.44 / $16,982.44
| Facility | | $7,943.28 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $7,943.28 / $7,943.28
| Professional | | $3,890.45 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $12,302.69
| Facility | | $7,943.28 | $7,943.28 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,943.28 / $12,302.69
| Facility | | $5,888.44 | $7,943.28 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $60.26 / $70.79
| Professional | | $54.95 | $60.26 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $5,888.44
| Facility | | $64.57 | $64.57 | $5,888.44 |