- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $16,218.10 / $16,218.10
| Facility | | $10,232.93 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $6,165.95
| Professional | | $2,691.53 | $2,691.53 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $16,218.10 / $18,197.01
| Facility | | $0.02 | $16,218.10 | $18,197.01 |
- 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
- $23,442.29 / $23,442.29 / $23,442.29
| Facility | | $23,442.29 | $23,442.29 | $23,442.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Facility | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,570.88 / $10,964.78
| Professional | | $3,162.28 | $4,570.88 | $10,964.78 |