- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,631.57 / $19,539.50 / $19,539.50
| Facility | | $15,631.57 | $19,539.50 | $19,539.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,631.57 / $15,631.57 / $15,631.57
| Professional | | $15,631.57 | $15,631.57 | $15,631.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,852.49 / $31,121.48 / $60,684.63
| Facility | | $23,852.49 | $31,121.48 | $60,684.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,157.73 / $3,323.92 / $3,323.92
| Professional | | $3,157.73 | $3,323.92 | $3,323.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,201.13 / $5,251.41 / $9,260.83
| Professional | | $4,201.13 | $5,251.41 | $9,260.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,314.91 / $15,631.57 / $73,272.98
| Facility | | $4,314.91 | $15,631.57 | $73,272.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,282.88 / $16,282.88 / $19,539.46
| Professional | | $16,282.88 | $16,282.88 | $19,539.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,487.31 / $6,472.37 / $10,140.04
| Facility | | $4,487.31 | $6,472.37 | $10,140.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,509.21 / $6,055.82 / $9,260.83
| Professional | | $4,509.21 | $6,055.82 | $9,260.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,468.74 / $16,282.88 / $19,539.46
| Professional | | $15,468.74 | $16,282.88 | $19,539.46 |