- 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
- $12,589.25 / $15,488.17 / $24,547.09
| Professional | | $12,589.25 | $15,488.17 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,877.62 / $26,302.68 / $26,915.35
| Professional | | $21,877.62 | $26,302.68 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,378.01 / $23,442.29 / $27,542.29
| Professional | | $17,378.01 | $23,442.29 | $27,542.29 |
- 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 / $42,657.95
| Professional | | $11,748.98 | $11,748.98 | $42,657.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,442.29 / $28,840.32 / $43,651.58
| Professional | | $23,442.29 | $28,840.32 | $43,651.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $21,379.62 / $28,840.32
| Facility | | $8,317.64 | $21,379.62 | $28,840.32 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $19,498.45 / $35,481.34
| Facility | | $10,000.00 | $19,498.45 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,022.64 / $14,125.38 / $19,498.45
| Professional | | $12,022.64 | $14,125.38 | $19,498.45 |