- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,531.65 / $10,742.80 / $29,767.52
| Facility | | $3,531.65 | $10,742.80 | $29,767.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.30 / $673.30 / $10,294.60
| Professional | | $673.30 | $673.30 | $10,294.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.25 / $362.25 / $362.25
| Professional | | $362.25 | $362.25 | $362.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $673.30 / $861.82 / $1,232.14
| Facility | | $673.30 | $861.82 | $1,232.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,831.58 / $27,841.54 / $35,402.06
| Facility | | $19,831.58 | $27,841.54 | $35,402.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,000.00 / $62,445.00 / $76,459.00
| Facility | | $12,000.00 | $62,445.00 | $76,459.00 |