- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,735.48 / $11,164.89 / $11,164.89
| Facility | | $10,735.48 | $11,164.89 | $11,164.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.87 / $10,955.24 / $11,958.93
| Professional | | $9,772.87 | $10,955.24 | $11,958.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,042.29 / $22,557.89 / $23,708.34
| Facility | | $14,042.29 | $22,557.89 | $23,708.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,550.78 / $12,037.84 / $12,489.26
| Professional | | $10,550.78 | $12,037.84 | $12,489.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,918.41 / $31,410.85 / $36,132.53
| Facility | | $16,918.41 | $31,410.85 | $36,132.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,430.00 / $28,045.40 / $37,220.51
| Professional | | $21,430.00 | $28,045.40 | $37,220.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,513.81 / $14,513.81 / $26,435.03
| Facility | | $14,513.81 | $14,513.81 | $26,435.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,595.08 / $14,513.81 / $107,604.38
| Professional | | $10,595.08 | $14,513.81 | $107,604.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,123.54 / $13,565.30 / $16,956.62
| Professional | | $11,123.54 | $13,565.30 | $16,956.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,502.59 / $11,253.89 / $15,301.50
| Professional | | $7,502.59 | $11,253.89 | $15,301.50 |