- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $7,585.78 / $13,803.84
| Professional | | $6,760.83 | $7,585.78 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $21,877.62
| Facility | | $10,471.29 | $10,471.29 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,481.54 / $11,481.54 / $19,498.45
| Professional | | $11,481.54 | $11,481.54 | $19,498.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $25,703.96 / $25,703.96
| Facility | | $10,000.00 | $25,703.96 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $77,624.71
| Professional | | $7,244.36 | $7,244.36 | $77,624.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $9,549.93 / $16,595.87
| Facility | | $6,606.93 | $9,549.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $10,000.00 / $12,882.50
| Professional | | $7,244.36 | $10,000.00 | $12,882.50 |