- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,628.02 / $12,628.02 / $12,628.02
| Facility | | $12,628.02 | $12,628.02 | $12,628.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,628.02 / $14,089.17 / $125,471.00
| Professional | | $12,628.02 | $14,089.17 | $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 / $32,398.44
| Professional | | $22,185.52 | $30,391.12 | $32,398.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,396.34 / $31,284.43 / $40,669.75
| Professional | | $19,396.34 | $31,284.43 | $40,669.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37,524.39 / $41,849.51 / $41,849.51
| Facility | | $37,524.39 | $41,849.51 | $41,849.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,830.58 / $29,997.74 / $44,996.61
| Professional | | $23,830.58 | $29,997.74 | $44,996.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,661.55 / $19,560.65 / $28,062.26
| Professional | | $17,661.55 | $19,560.65 | $28,062.26 |