- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $15,848.93 / $15,848.93
| Facility | | $15,848.93 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,125.38 / $15,848.93 / $18,197.01
| Professional | | $14,125.38 | $15,848.93 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,378.01 / $17,378.01 / $30,902.95
| Facility | | $17,378.01 | $17,378.01 | $30,902.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61,659.50 / $87,096.36 / $208,929.61
| Facility | | $61,659.50 | $87,096.36 | $208,929.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,302.68 / $30,902.95 / $33,113.11
| Professional | | $26,302.68 | $30,902.95 | $33,113.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67,608.30 / $83,176.38 / $165,958.69
| Facility | | $67,608.30 | $83,176.38 | $165,958.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,302.68 / $26,302.68 / $35,481.34
| Professional | | $26,302.68 | $26,302.68 | $35,481.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,125.38 / $30,199.52 / $45,708.82
| Facility | | $14,125.38 | $30,199.52 | $45,708.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43,651.58 / $44,668.36 / $61,659.50
| Facility | | $43,651.58 | $44,668.36 | $61,659.50 |