- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,570.88 / $7,943.28
| Facility | | $2,454.71 | $4,570.88 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,715.35 / $4,786.30
| Professional | | $2,818.38 | $3,715.35 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,884.03 / $5,248.07
| Facility | | $1,819.70 | $2,884.03 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,630.78 / $3,890.45
| Facility | | $2,884.03 | $3,630.78 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,630.27 / $4,570.88
| Facility | | $1,819.70 | $2,630.27 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Facility | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $10,232.93 / $37,153.52
| Facility | | $2,454.71 | $10,232.93 | $37,153.52 |