- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $12,302.69
| Facility | | $6,918.31 | $6,918.31 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $7,762.47 / $13,489.63
| Professional | | $6,760.83 | $7,762.47 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,302.69 / $12,302.69 / $12,882.50
| Professional | | $12,302.69 | $12,302.69 | $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 / $10,000.00
| Professional | | $7,244.36 | $7,244.36 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77,624.71 / $77,624.71 / $77,624.71
| Facility | | $77,624.71 | $77,624.71 | $77,624.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95,499.26 / $109,647.82 / $109,647.82
| Professional | | $95,499.26 | $109,647.82 | $109,647.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,549.93 / $11,220.18
| Facility | | $5,495.41 | $9,549.93 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $7,762.47 / $10,964.78
| Professional | | $5,370.32 | $7,762.47 | $10,964.78 |