- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $7,762.47 / $7,762.47
| Facility | | $2,041.74 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,488.17 / $15,488.17 / $15,488.17
| Professional | | $15,488.17 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,547.09 / $54,954.09 / $83,176.38
| Facility | | $24,547.09 | $54,954.09 | $83,176.38 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $85.11
| Professional | | $60.26 | $60.26 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $21,379.62 / $79,432.82
| Facility | | $1,659.59 | $21,379.62 | $79,432.82 |