- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,250.00
| Facility | | $960.00 | $1,728.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,536.72 / $16,536.72 / $16,536.72
| Professional | | $16,536.72 | $16,536.72 | $16,536.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,648.86 / $16,563.53 / $22,283.25
| Facility | | $13,648.86 | $16,563.53 | $22,283.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,800.00 / $3,800.00 / $11,745.00
| Facility | | $3,800.00 | $3,800.00 | $11,745.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,404.00 / $4,852.00 / $9,624.00
| Facility | | $1,404.00 | $4,852.00 | $9,624.00 |