- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,912.51 / $11,220.18 / $74,131.02
| Professional | | $8,912.51 | $11,220.18 | $74,131.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,488.17 / $16,982.44 / $16,982.44
| Professional | | $15,488.17 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $19,498.45
| Facility | | $9,772.37 | $9,772.37 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $20,417.38 / $30,199.52
| Professional | | $9,772.37 | $20,417.38 | $30,199.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $19,498.45 / $81,283.05
| Facility | | $11,220.18 | $19,498.45 | $81,283.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,471.29 / $14,454.40
| Professional | | $6,456.54 | $10,471.29 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,054.61 / $23,988.33 / $43,651.58
| Professional | | $19,054.61 | $23,988.33 | $43,651.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,498.45 / $19,498.45 / $19,498.45
| Facility | | $19,498.45 | $19,498.45 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,988.33 / $30,199.52 / $43,651.58
| Professional | | $23,988.33 | $30,199.52 | $43,651.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $12,302.69 / $18,197.01
| Facility | | $10,471.29 | $12,302.69 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $8,709.64 / $13,489.63
| Professional | | $6,456.54 | $8,709.64 | $13,489.63 |