- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,877.62 / $21,877.62 / $21,877.62
| Facility | | $21,877.62 | $21,877.62 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,589.25 / $16,595.87 / $21,877.62
| Professional | | $12,589.25 | $16,595.87 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,877.62 / $21,877.62 / $21,877.62
| Professional | | $21,877.62 | $21,877.62 | $21,877.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,988.33 / $28,840.32 / $57,543.99
| Facility | | $23,988.33 | $28,840.32 | $57,543.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,877.62 / $22,387.21 / $24,547.09
| Professional | | $21,877.62 | $22,387.21 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,218.10
| Facility | | $16,218.10 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $33,884.42
| Professional | | $11,748.98 | $11,748.98 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $14,454.40 / $19,054.61
| Professional | | $13,489.63 | $14,454.40 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $23,442.29 / $40,738.03
| Facility | | $12,022.64 | $23,442.29 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $19,498.45 / $23,442.29
| Facility | | $10,715.19 | $19,498.45 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,481.54 / $14,454.40 / $20,417.38
| Professional | | $11,481.54 | $14,454.40 | $20,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134,896.29 / $134,896.29 / $134,896.29
| Facility | | $134,896.29 | $134,896.29 | $134,896.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144,543.98 / $144,543.98 / $213,796.21
| Professional | | $144,543.98 | $144,543.98 | $213,796.21 |