- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,025.60 / $15,488.17
| Facility | | $2,951.21 | $6,025.60 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,912.51 / $15,488.17 / $15,488.17
| Professional | | $8,912.51 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $25,703.96 / $56,234.13
| Facility | | $15,848.93 | $25,703.96 | $56,234.13 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $12,882.50 / $12,882.50 / $13,182.57
| Professional | | $12,882.50 | $12,882.50 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,489.63 / $19,054.61 / $32,359.37
| Facility | | $13,489.63 | $19,054.61 | $32,359.37 |