- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,386.13 / $18,386.13 / $18,386.13
| Facility | | $18,386.13 | $18,386.13 | $18,386.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,386.13 / $18,386.13 / $21,679.16
| Professional | | $18,386.13 | $18,386.13 | $21,679.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25,339.91 / $27,873.91 / $28,155.47
| Professional | | $25,339.91 | $27,873.91 | $28,155.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,200.25 / $31,714.32 / $31,714.32
| Facility | | $16,200.25 | $31,714.32 | $31,714.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,200.25 / $31,714.32 / $48,904.12
| Professional | | $16,200.25 | $31,714.32 | $48,904.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,519.19 / $31,256.42 / $134,932.92
| Facility | | $14,519.19 | $31,256.42 | $134,932.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,976.79 / $17,245.77 / $28,300.96
| Professional | | $10,976.79 | $17,245.77 | $28,300.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31,621.54 / $31,714.32 / $39,958.93
| Facility | | $31,621.54 | $31,714.32 | $39,958.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25,974.18 / $37,480.56 / $65,336.65
| Professional | | $25,974.18 | $37,480.56 | $65,336.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29,383.10 / $29,383.10 / $29,383.10
| Facility | | $29,383.10 | $29,383.10 | $29,383.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,976.79 / $14,383.57 / $19,931.41
| Professional | | $10,976.79 | $14,383.57 | $19,931.41 |