- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,918.31
| Facility | | $4,897.79 | $4,897.79 | $6,918.31 |
- 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
- 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
- $4,897.79 / $4,897.79 / $6,918.31
| Facility | | $4,897.79 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,488.17 / $15,488.17 / $48,977.88
| Professional | | $15,488.17 | $15,488.17 | $48,977.88 |
- 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
- $6,918.31 / $12,589.25 / $37,153.52
| Facility | | $6,918.31 | $12,589.25 | $37,153.52 |