- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $5,888.44
| Facility | | $933.25 | $2,691.53 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $15,488.17 / $15,488.17
| Professional | | $3,890.45 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $17,378.01 / $24,547.09
| Facility | | $9,772.37 | $17,378.01 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,218.10
| Facility | | $16,218.10 | $16,218.10 | $16,218.10 |
- 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
- $1,202.26 / $10,232.93 / $26,302.68
| Facility | | $1,202.26 | $10,232.93 | $26,302.68 |