- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,791.08 / $14,791.08 / $14,791.08
| Facility | | $14,791.08 | $14,791.08 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $9,772.37 / $14,791.08
| Professional | | $7,413.10 | $9,772.37 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $17,378.01 / $25,703.96
| Facility | | $16,982.44 | $17,378.01 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,125.38 / $17,378.01 / $17,378.01
| Professional | | $14,125.38 | $17,378.01 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38,018.94 / $66,069.34 / $158,489.32
| Facility | | $38,018.94 | $66,069.34 | $158,489.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,417.38 / $22,908.68 / $25,703.96
| Professional | | $20,417.38 | $22,908.68 | $25,703.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50,118.72 / $64,565.42 / $123,026.88
| Facility | | $50,118.72 | $64,565.42 | $123,026.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,417.38 / $20,417.38 / $27,542.29
| Professional | | $20,417.38 | $20,417.38 | $27,542.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $17,378.01 / $31,622.78
| Facility | | $11,748.98 | $17,378.01 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $7,762.47 / $19,054.61
| Professional | | $5,248.07 | $7,762.47 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.89 / $10,471.29 / $21,379.62
| Facility | | $125.89 | $10,471.29 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $8,709.64 / $20,417.38
| Professional | | $5,248.07 | $8,709.64 | $20,417.38 |