- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,821.91 / $15,821.91 / $15,821.91
| Facility | | $15,821.91 | $15,821.91 | $15,821.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,821.91 / $15,821.91 / $15,821.91
| Professional | | $15,821.91 | $15,821.91 | $15,821.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,850.99 / $17,609.75 / $39,474.03
| Facility | | $16,850.99 | $17,609.75 | $39,474.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58,799.29 / $83,384.70 / $200,593.18
| Facility | | $58,799.29 | $83,384.70 | $200,593.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,440.92 / $30,716.84 / $33,247.49
| Professional | | $26,440.92 | $30,716.84 | $33,247.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46,298.66 / $76,233.61 / $157,947.39
| Facility | | $46,298.66 | $76,233.61 | $157,947.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,179.13 / $26,179.13 / $29,844.20
| Professional | | $26,179.13 | $26,179.13 | $29,844.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,126.71 / $26,739.03 / $45,296.67
| Facility | | $14,126.71 | $26,739.03 | $45,296.67 |