- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,679.16 / $21,679.16 / $21,679.16
| Facility | | $21,679.16 | $21,679.16 | $21,679.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,350.18 / $15,093.09 / $24,148.94
| Professional | | $8,350.18 | $15,093.09 | $24,148.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,819.53 / $24,020.56 / $25,551.45
| Facility | | $22,819.53 | $24,020.56 | $25,551.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25,221.59 / $25,221.59 / $25,221.59
| Professional | | $25,221.59 | $25,221.59 | $25,221.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,200.25 / $16,200.25 / $16,200.25
| Facility | | $16,200.25 | $16,200.25 | $16,200.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,826.18 / $16,200.25 / $41,996.25
| Professional | | $11,826.18 | $16,200.25 | $41,996.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,350.18 / $22,329.53 / $134,932.92
| Facility | | $8,350.18 | $22,329.53 | $134,932.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,622.87 / $15,411.37 / $36,833.58
| Professional | | $8,622.87 | $15,411.37 | $36,833.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29,383.10 / $29,383.10 / $34,568.35
| Facility | | $29,383.10 | $29,383.10 | $34,568.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,589.04 / $14,383.57 / $19,931.41
| Professional | | $9,589.04 | $14,383.57 | $19,931.41 |