- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,237.72 / $14,237.72 / $14,237.72
| Facility | | $14,237.72 | $14,237.72 | $14,237.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,237.72 / $14,237.72 / $16,787.75
| Professional | | $14,237.72 | $14,237.72 | $16,787.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,622.56 / $21,584.81 / $21,802.84
| Professional | | $19,622.56 | $21,584.81 | $21,802.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,513.81 / $24,558.72 / $24,558.72
| Facility | | $14,513.81 | $24,558.72 | $24,558.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,513.81 / $24,558.72 / $37,870.05
| Professional | | $14,513.81 | $24,558.72 | $37,870.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,240.68 / $24,204.12 / $104,478.94
| Facility | | $11,240.68 | $24,204.12 | $104,478.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,500.12 / $13,213.37 / $18,563.75
| Professional | | $8,500.12 | $13,213.37 | $18,563.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,486.86 / $24,558.72 / $30,943.14
| Facility | | $24,486.86 | $24,558.72 | $30,943.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,113.72 / $29,023.94 / $50,594.97
| Professional | | $20,113.72 | $29,023.94 | $50,594.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,500.12 / $13,213.37 / $15,408.48
| Professional | | $8,500.12 | $13,213.37 | $15,408.48 |