- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,219.84 / $17,219.84 / $17,219.84
| Professional | | $17,219.84 | $17,219.84 | $17,219.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,102.62 / $10,102.62 / $10,102.62
| Facility | | $10,102.62 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,587.24 / $10,102.62 / $10,102.62
| Professional | | $8,587.24 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,191.44 / $9,260.70 / $13,775.87
| Facility | | $6,191.44 | $9,260.70 | $13,775.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,562.46 / $1,562.46 / $1,644.69
| Professional | | $1,562.46 | $1,562.46 | $1,644.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,105.10 / $13,675.30 / $35,108.79
| Professional | | $9,105.10 | $13,675.30 | $35,108.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,191.44 / $9,649.01 / $13,619.33
| Facility | | $6,191.44 | $9,649.01 | $13,619.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,587.24 / $10,102.62 / $10,102.62
| Professional | | $8,587.24 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,470.12 / $10,484.40 / $19,145.43
| Professional | | $5,470.12 | $10,484.40 | $19,145.43 |