- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,126.71 / $14,126.71 / $30,039.94
| Facility | | $14,126.71 | $14,126.71 | $30,039.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,126.71 / $15,821.91 / $18,228.47
| Professional | | $14,126.71 | $15,821.91 | $18,228.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $818.35 / $40,889.86 / $47,014.54
| Facility | | $818.35 | $40,889.86 | $47,014.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,087.50 / $16,087.50 / $16,087.50
| Professional | | $16,087.50 | $16,087.50 | $16,087.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,485.09 / $17,485.09 / $24,609.11
| Professional | | $17,485.09 | $17,485.09 | $24,609.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |