- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,045.54 / $27,045.54 / $27,045.54
| Facility | | $27,045.54 | $27,045.54 | $27,045.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,548.73 / $36,919.31 / $125,471.00
| Professional | | $23,548.73 | $36,919.31 | $125,471.00 |
- 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 / $30,391.12
| Professional | | $22,185.52 | $30,391.12 | $30,391.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39,221.29 / $49,026.62 / $73,539.92
| Professional | | $39,221.29 | $49,026.62 | $73,539.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,628.02 / $12,628.02 / $36,843.81
| Facility | | $12,628.02 | $12,628.02 | $36,843.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,185.52 / $30,391.12 / $51,532.14
| Professional | | $22,185.52 | $30,391.12 | $51,532.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,085.41 / $19,560.65 / $29,933.07
| Professional | | $18,085.41 | $19,560.65 | $29,933.07 |