- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,981.07 / $7,762.47
| Facility | | $1,380.38 | $3,981.07 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $15,488.17 / $15,488.17
| Professional | | $6,606.93 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $19,498.45 / $32,359.37
| Facility | | $12,589.25 | $19,498.45 | $32,359.37 |
- 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
- $3,235.94 / $9,549.93 / $21,379.62
| Facility | | $3,235.94 | $9,549.93 | $21,379.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $12,302.69 / $21,379.62
| Facility | | $3,467.37 | $12,302.69 | $21,379.62 |