- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,620.87 / $18,620.87 / $18,620.87
| Facility | | $18,620.87 | $18,620.87 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $12,022.64 / $18,620.87
| Professional | | $9,549.93 | $12,022.64 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,877.62 / $22,387.21 / $33,113.11
| Facility | | $21,877.62 | $22,387.21 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,782.79 / $22,387.21 / $22,387.21
| Professional | | $17,782.79 | $22,387.21 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48,977.88 / $85,113.80 / $199,526.23
| Facility | | $48,977.88 | $85,113.80 | $199,526.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,302.68 / $29,512.09 / $33,113.11
| Professional | | $26,302.68 | $29,512.09 | $33,113.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64,565.42 / $81,283.05 / $158,489.32
| Facility | | $64,565.42 | $81,283.05 | $158,489.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,302.68 / $26,302.68 / $35,481.34
| Professional | | $26,302.68 | $26,302.68 | $35,481.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $22,387.21 / $45,708.82
| Facility | | $9,549.93 | $22,387.21 | $45,708.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,000.00 / $24,547.09
| Professional | | $6,606.93 | $10,000.00 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $13,182.57 / $27,542.29
| Facility | | $158.49 | $13,182.57 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $11,220.18 / $26,302.68
| Professional | | $6,606.93 | $11,220.18 | $26,302.68 |