- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,244.36 / $10,232.93
| Professional | | $5,888.44 | $7,244.36 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,511.38 / $8,511.38
| Facility | | $8,128.31 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $8,511.38 / $8,511.38
| Professional | | $6,760.83 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,387.21 / $32,359.37 / $77,624.71
| Facility | | $22,387.21 | $32,359.37 | $77,624.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $12,302.69 / $17,378.01
| Professional | | $9,772.37 | $12,302.69 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,118.86 / $30,199.52 / $61,659.50
| Facility | | $25,118.86 | $30,199.52 | $61,659.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $16,218.10
| Professional | | $9,772.37 | $9,772.37 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $13,803.84 / $20,417.38
| Facility | | $7,585.78 | $13,803.84 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,128.61 / $22,387.21
| Professional | | $3,548.13 | $5,128.61 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $10,232.93
| Facility | | $8,511.38 | $8,511.38 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $7,079.46 / $18,197.01
| Professional | | $3,548.13 | $7,079.46 | $18,197.01 |