- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,630.27 / $6,456.54
| Facility | | $1,096.48 | $2,630.27 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $15,488.17 / $15,488.17
| Professional | | $2,570.40 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $10,471.29 / $16,595.87
| Facility | | $3,388.44 | $10,471.29 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $16,595.87
| Facility | | $16,595.87 | $16,595.87 | $16,595.87 |
- 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
- $70,794.58 / $70,794.58 / $70,794.58
| Facility | | $70,794.58 | $70,794.58 | $70,794.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,232.93 / $19,952.62
| Facility | | $6,456.54 | $10,232.93 | $19,952.62 |