- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,892.96 / $20,892.96 / $20,892.96
| Facility | | $20,892.96 | $20,892.96 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,378.01 / $20,892.96 / $34,673.69
| Professional | | $17,378.01 | $20,892.96 | $34,673.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186,208.71 / $186,208.71 / $186,208.71
| Facility | | $186,208.71 | $186,208.71 | $186,208.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,595.87 / $22,387.21 / $58,884.37
| Professional | | $16,595.87 | $22,387.21 | $58,884.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,902.95 / $30,902.95 / $44,668.36
| Professional | | $30,902.95 | $30,902.95 | $44,668.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34,673.69 / $34,673.69 / $52,480.75
| Professional | | $34,673.69 | $34,673.69 | $52,480.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186,208.71 / $186,208.71 / $186,208.71
| Facility | | $186,208.71 | $186,208.71 | $186,208.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,595.87 / $23,442.29 / $60,255.96
| Professional | | $16,595.87 | $23,442.29 | $60,255.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.11 / $23,442.29 / $44,668.36
| Facility | | $33.11 | $23,442.29 | $44,668.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,595.87 / $28,183.83 / $37,153.52
| Professional | | $16,595.87 | $28,183.83 | $37,153.52 |