- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $8,317.64 / $12,882.50
| Professional | | $6,760.83 | $8,317.64 | $12,882.50 |
- 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
- $7,244.36 / $7,244.36 / $16,218.10
| Professional | | $7,244.36 | $7,244.36 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $9,549.93 / $47,863.01
| Facility | | $6,606.93 | $9,549.93 | $47,863.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $8,128.31 / $20,417.38
| Professional | | $4,786.30 | $8,128.31 | $20,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $12,302.69 / $16,595.87
| Facility | | $6,606.93 | $12,302.69 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,244.36 / $10,964.78
| Professional | | $4,786.30 | $7,244.36 | $10,964.78 |