- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,888.44 / $11,748.98
| Facility | | $1,445.44 | $5,888.44 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $15,488.17 / $15,488.17
| Professional | | $776.25 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $12,589.25 / $12,882.50
| Facility | | $323.59 | $12,589.25 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Professional | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,466.84 / $4,786.30
| Facility | | $4,168.69 | $4,466.84 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $15,488.17 / $27,542.29
| Facility | | $7,079.46 | $15,488.17 | $27,542.29 |