- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $4,570.88
| Facility | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,365.16 / $4,570.88
| Professional | | $2,884.03 | $4,365.16 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $851.14 / $1,288.25
| Facility | | $707.95 | $851.14 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $407.38
| Facility | | $199.53 | $199.53 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $3,311.31 / $8,128.31
| Professional | | $199.53 | $3,311.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $4,570.88 / $5,011.87
| Facility | | $602.56 | $4,570.88 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $2,187.76 / $3,981.07
| Facility | | $309.03 | $2,187.76 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,818.38 / $4,570.88
| Professional | | $2,187.76 | $2,818.38 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $26,302.68 / $26,302.68
| Facility | | $8,511.38 | $26,302.68 | $26,302.68 |