- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32,613.62 / $32,613.62 / $32,613.62
| Facility | | $32,613.62 | $32,613.62 | $32,613.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,628.02 / $22,705.68 / $36,329.08
| Professional | | $12,628.02 | $22,705.68 | $36,329.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52,945.53 / $52,945.53 / $52,945.53
| Professional | | $52,945.53 | $52,945.53 | $52,945.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30,391.12 / $30,391.12 / $30,391.12
| Facility | | $30,391.12 | $30,391.12 | $30,391.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,185.52 / $30,391.12 / $68,080.78
| Professional | | $22,185.52 | $30,391.12 | $68,080.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,628.02 / $34,955.14 / $202,594.16
| Facility | | $12,628.02 | $34,955.14 | $202,594.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,040.44 / $24,834.33 / $55,411.60
| Professional | | $13,040.44 | $24,834.33 | $55,411.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,425.54 / $21,638.30 / $30,142.37
| Professional | | $14,425.54 | $21,638.30 | $30,142.37 |