- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Facility | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,413.10 / $11,748.98
| Professional | | $5,495.41 | $7,413.10 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $14,125.38 / $20,417.38
| Facility | | $13,803.84 | $14,125.38 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $14,125.38 / $14,125.38
| Professional | | $11,220.18 | $14,125.38 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29,512.09 / $52,480.75 / $125,892.54
| Facility | | $29,512.09 | $52,480.75 | $125,892.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $18,620.87 / $20,892.96
| Professional | | $16,218.10 | $18,620.87 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40,738.03 / $52,480.75 / $100,000.00
| Facility | | $40,738.03 | $52,480.75 | $100,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $21,877.62
| Professional | | $16,218.10 | $16,218.10 | $21,877.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $14,125.38 / $28,183.83
| Facility | | $5,754.40 | $14,125.38 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,165.95 / $14,125.38
| Professional | | $4,073.80 | $6,165.95 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.72 / $8,128.31 / $16,595.87
| Facility | | $97.72 | $8,128.31 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,760.83 / $16,218.10
| Professional | | $4,073.80 | $6,760.83 | $16,218.10 |