- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $82,287.60 / $82,287.60 / $82,287.60
| Facility | | $82,287.60 | $82,287.60 | $82,287.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,169.00 / $11,476.59 / $12,343.64
| Professional | | $11,169.00 | $11,476.59 | $12,343.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,213.01 / $31,020.71 / $40,958.10
| Facility | | $15,213.01 | $31,020.71 | $40,958.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,213.01 / $16,383.24 / $27,573.96
| Professional | | $15,213.01 | $16,383.24 | $27,573.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,034.23 / $13,034.23 / $26,927.70
| Facility | | $13,034.23 | $13,034.23 | $26,927.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,079.10 / $13,034.23 / $103,282.86
| Professional | | $11,079.10 | $13,034.23 | $103,282.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,719.54 / $19,719.54 / $112,155.49
| Facility | | $19,719.54 | $19,719.54 | $112,155.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,676.31 / $14,537.05 / $19,460.52
| Professional | | $11,676.31 | $14,537.05 | $19,460.52 |