- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,659.65 / $27,659.65 / $27,659.65
| Facility | | $27,659.65 | $27,659.65 | $27,659.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,659.65 / $27,659.65 / $32,613.62
| Professional | | $27,659.65 | $27,659.65 | $32,613.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38,120.76 / $41,932.86 / $42,356.41
| Professional | | $38,120.76 | $41,932.86 | $42,356.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30,391.12 / $47,710.27 / $47,710.27
| Facility | | $30,391.12 | $47,710.27 | $47,710.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,391.12 / $47,710.27 / $73,570.23
| Professional | | $30,391.12 | $47,710.27 | $73,570.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,537.37 / $47,475.52 / $202,594.16
| Facility | | $23,537.37 | $47,475.52 | $202,594.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,513.22 / $26,080.87 / $36,063.83
| Professional | | $16,513.22 | $26,080.87 | $36,063.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47,570.68 / $47,710.27 / $60,113.29
| Facility | | $47,570.68 | $47,710.27 | $60,113.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39,074.94 / $56,384.86 / $98,290.94
| Professional | | $39,074.94 | $56,384.86 | $98,290.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,513.22 / $21,638.30 / $30,142.37
| Professional | | $16,513.22 | $21,638.30 | $30,142.37 |