- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193,694.95 / $193,694.95 / $209,165.38
| Facility | | $193,694.95 | $193,694.95 | $209,165.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,984.53 / $15,477.02 / $15,477.02
| Professional | | $10,984.53 | $15,477.02 | $15,477.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,562.19 / $13,311.26 / $17,252.31
| Professional | | $12,562.19 | $13,311.26 | $17,252.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,034.23 / $13,034.23 / $16,890.03
| Facility | | $13,034.23 | $13,034.23 | $16,890.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,079.10 / $11,079.10 / $13,034.23
| Professional | | $11,079.10 | $11,079.10 | $13,034.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193,694.95 / $193,694.95 / $209,165.38
| Facility | | $193,694.95 | $193,694.95 | $209,165.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,939.23 / $15,477.02 / $15,477.02
| Professional | | $12,939.23 | $15,477.02 | $15,477.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,642.97 / $11,464.46 / $26,364.70
| Professional | | $7,642.97 | $11,464.46 | $26,364.70 |