- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Facility | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,302.69 / $14,454.40 / $25,118.86
| Professional | | $12,302.69 | $14,454.40 | $25,118.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,840.32 / $28,840.32 / $30,199.52
| Facility | | $28,840.32 | $28,840.32 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,417.38 / $22,387.21 / $22,387.21
| Professional | | $20,417.38 | $22,387.21 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $22,387.21
| Facility | | $16,595.87 | $16,595.87 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $12,022.64 / $16,595.87
| Professional | | $436.52 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $28,840.32 / $50,118.72
| Professional | | $16,218.10 | $28,840.32 | $50,118.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,840.32 / $29,512.09
| Professional | | $28,183.83 | $28,840.32 | $29,512.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $9,772.37 / $19,498.45
| Facility | | $371.54 | $9,772.37 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $19,952.62 / $26,302.68
| Professional | | $10,000.00 | $19,952.62 | $26,302.68 |