- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,497.00 / $35,903.60 / $90,880.12
| Facility | | $13,497.00 | $35,903.60 | $90,880.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,497.00 / $14,126.71 / $19,968.25
| Professional | | $13,497.00 | $14,126.71 | $19,968.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,754.57 / $18,359.36 / $21,856.38
| Facility | | $9,754.57 | $18,359.36 | $21,856.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,087.50 / $16,087.50 / $16,087.50
| Professional | | $16,087.50 | $16,087.50 | $16,087.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,970.00 / $9,970.00 / $9,970.00
| Professional | | $9,970.00 | $9,970.00 | $9,970.00 |