- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $15,848.93
| Facility | | $10,000.00 | $10,000.00 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $10,000.00 / $16,218.10
| Professional | | $7,762.47 | $10,000.00 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,125.38 / $14,125.38 / $14,125.38
| Facility | | $14,125.38 | $14,125.38 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,125.38 / $14,125.38 / $14,125.38
| Professional | | $14,125.38 | $14,125.38 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $12,589.25 / $12,589.25
| Facility | | $12,589.25 | $12,589.25 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $12,589.25
| Professional | | $9,120.11 | $9,120.11 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $14,454.40 / $23,988.33
| Facility | | $9,332.54 | $14,454.40 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $8,709.64 / $13,489.63
| Professional | | $5,888.44 | $8,709.64 | $13,489.63 |