- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $12,882.50 / $12,882.50
| Facility | | $12,882.50 | $12,882.50 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $12,882.50 / $97,723.72
| Professional | | $10,715.19 | $12,882.50 | $97,723.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,782.79 / $19,952.62 / $19,952.62
| Professional | | $17,782.79 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $13,803.84 / $22,908.68
| Facility | | $13,803.84 | $13,803.84 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,803.84 / $24,547.09 / $37,153.52
| Professional | | $13,803.84 | $24,547.09 | $37,153.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $22,908.68 / $100,000.00
| Facility | | $12,882.50 | $22,908.68 | $100,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $12,589.25 / $20,892.96
| Professional | | $6,760.83 | $12,589.25 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,387.21 / $22,387.21 / $51,286.14
| Professional | | $22,387.21 | $22,387.21 | $51,286.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,908.68 / $22,908.68 / $22,908.68
| Facility | | $22,908.68 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $51,286.14 / $51,286.14
| Professional | | $28,183.83 | $51,286.14 | $51,286.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $14,454.40 / $22,387.21
| Facility | | $12,589.25 | $14,454.40 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $10,232.93 / $15,488.17
| Professional | | $7,762.47 | $10,232.93 | $15,488.17 |