- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $12,882.50 / $12,882.50
| Facility | | $12,882.50 | $12,882.50 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $12,589.25 / $19,952.62
| Professional | | $9,772.37 | $12,589.25 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56,234.13 / $69,183.10 / $81,283.05
| Facility | | $56,234.13 | $69,183.10 | $81,283.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,803.84 / $18,620.87 / $21,877.62
| Professional | | $13,803.84 | $18,620.87 | $21,877.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,182.57 / $13,182.57 / $13,182.57
| Facility | | $13,182.57 | $13,182.57 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,964.78 / $10,964.78 / $34,673.69
| Professional | | $10,964.78 | $10,964.78 | $34,673.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,620.87 / $23,442.29 / $34,673.69
| Professional | | $18,620.87 | $23,442.29 | $34,673.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $17,378.01 / $23,988.33
| Facility | | $6,760.83 | $17,378.01 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,964.78 / $10,964.78 / $26,915.35
| Professional | | $10,964.78 | $10,964.78 | $26,915.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $13,803.84 / $23,442.29
| Facility | | $7,943.28 | $13,803.84 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $12,022.64 / $15,848.93
| Professional | | $9,549.93 | $12,022.64 | $15,848.93 |