- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,634.73 / $24,634.73 / $24,634.73
| Facility | | $24,634.73 | $24,634.73 | $24,634.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24,634.73 / $24,634.73 / $24,634.73
| Professional | | $24,634.73 | $24,634.73 | $24,634.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33,951.82 / $37,347.00 / $37,724.23
| Professional | | $33,951.82 | $37,347.00 | $37,724.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42,492.59 / $42,492.59 / $42,492.59
| Facility | | $42,492.59 | $42,492.59 | $42,492.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40,445.08 / $42,492.59 / $56,172.19
| Professional | | $40,445.08 | $42,492.59 | $56,172.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,634.73 / $41,879.04 / $182,487.33
| Facility | | $24,634.73 | $41,879.04 | $182,487.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,707.30 / $20,295.25 / $33,825.43
| Professional | | $14,707.30 | $20,295.25 | $33,825.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42,368.25 / $42,492.59 / $52,659.26
| Facility | | $42,368.25 | $42,492.59 | $52,659.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42,368.25 / $50,218.52 / $81,122.22
| Professional | | $42,368.25 | $50,218.52 | $81,122.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,707.30 / $20,295.25 / $33,123.69
| Professional | | $14,707.30 | $20,295.25 | $33,123.69 |