- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,125.38 / $14,125.38 / $14,125.38
| Facility | | $14,125.38 | $14,125.38 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $14,125.38 / $95,499.26
| Professional | | $11,220.18 | $14,125.38 | $95,499.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,498.45 / $21,379.62 / $21,877.62
| Professional | | $19,498.45 | $21,379.62 | $21,877.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $14,454.40 / $25,118.86
| Facility | | $14,454.40 | $14,454.40 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,454.40 / $26,302.68 / $38,904.51
| Professional | | $14,454.40 | $26,302.68 | $38,904.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,125.38 / $24,547.09 / $104,712.85
| Facility | | $14,125.38 | $24,547.09 | $104,712.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $13,182.57 / $22,387.21
| Professional | | $7,413.10 | $13,182.57 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24,547.09 / $24,547.09 / $56,234.13
| Professional | | $24,547.09 | $24,547.09 | $56,234.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,118.86 / $25,118.86 / $25,118.86
| Facility | | $25,118.86 | $25,118.86 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,902.95 / $56,234.13 / $56,234.13
| Professional | | $30,902.95 | $56,234.13 | $56,234.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,182.57 / $15,135.61 / $22,908.68
| Facility | | $13,182.57 | $15,135.61 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $11,220.18 / $16,982.44
| Professional | | $8,317.64 | $11,220.18 | $16,982.44 |