- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $12,022.64 / $15,135.61
| Professional | | $9,549.93 | $12,022.64 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Facility | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,054.61 / $19,054.61 / $23,988.33
| Professional | | $19,054.61 | $19,054.61 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $19,054.61 / $30,902.95
| Facility | | $8,709.64 | $19,054.61 | $30,902.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,128.61 / $9,120.11
| Professional | | $4,365.16 | $5,128.61 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,128.61 / $10,964.78
| Professional | | $3,630.78 | $5,128.61 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,791.08 / $14,791.08 / $14,791.08
| Professional | | $14,791.08 | $14,791.08 | $14,791.08 |