- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,635.23 / $21,635.23 / $34,481.14
| Facility | | $21,635.23 | $21,635.23 | $34,481.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,635.23 / $25,722.26 / $34,481.14
| Professional | | $21,635.23 | $25,722.26 | $34,481.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,846.68 / $3,846.68 / $3,846.68
| Facility | | $3,846.68 | $3,846.68 | $3,846.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33,805.04 / $33,805.04 / $33,805.04
| Professional | | $33,805.04 | $33,805.04 | $33,805.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31,019.05 / $31,019.05 / $31,019.05
| Professional | | $31,019.05 | $31,019.05 | $31,019.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $21.25 / $50.00
| Professional | | $17.00 | $21.25 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,249.48 / $20,283.02 / $32,114.79
| Professional | | $13,249.48 | $20,283.02 | $32,114.79 |