- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,499.54 / $12,499.54 / $12,499.54
| Facility | | $12,499.54 | $12,499.54 | $12,499.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,499.54 / $13,034.63 / $22,502.42
| Professional | | $12,499.54 | $13,034.63 | $22,502.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,595.62 / $76,402.92 / $134,932.92
| Facility | | $25,595.62 | $76,402.92 | $134,932.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,934.33 / $21,042.45 / $27,937.34
| Professional | | $12,934.33 | $21,042.45 | $27,937.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31,236.52 / $36,941.60 / $47,573.81
| Facility | | $31,236.52 | $36,941.60 | $47,573.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,065.72 / $24,047.17 / $24,047.17
| Professional | | $20,065.72 | $24,047.17 | $24,047.17 |
- 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 / $33,597.00
| Professional | | $11,826.18 | $16,200.25 | $33,597.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,162.50 / $23,162.50 / $24,320.62
| Professional | | $23,162.50 | $23,162.50 | $24,320.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,794.71 / $16,794.71 / $16,794.71
| Professional | | $16,794.71 | $16,794.71 | $16,794.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58,829.77 / $134,932.92 / $134,932.92
| Facility | | $58,829.77 | $134,932.92 | $134,932.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,174.94 / $15,291.98 / $27,937.34
| Professional | | $11,174.94 | $15,291.98 | $27,937.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34,568.35 / $34,568.35 / $34,568.35
| Facility | | $34,568.35 | $34,568.35 | $34,568.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,886.49 / $15,339.79 / $27,937.34
| Professional | | $12,886.49 | $15,339.79 | $27,937.34 |