- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.81 / $9,120.81 / $23,418.31
| Facility | | $9,120.81 | $9,120.81 | $23,418.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.81 / $12,668.38 / $23,418.31
| Professional | | $9,120.81 | $12,668.38 | $23,418.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,151.96 / $28,151.96 / $28,151.96
| Facility | | $28,151.96 | $28,151.96 | $28,151.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,850.80 / $22,275.00 / $34,363.97
| Professional | | $15,850.80 | $22,275.00 | $34,363.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,524.00 / $16,524.00 / $20,724.82
| Facility | | $16,524.00 | $16,524.00 | $20,724.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.07 / $12,062.52 / $17,615.41
| Professional | | $441.07 | $12,062.52 | $17,615.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,654.99 / $23,407.84 / $40,538.82
| Professional | | $15,654.99 | $23,407.84 | $40,538.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,067.57 / $12,857.86 / $21,429.76
| Professional | | $10,067.57 | $12,857.86 | $21,429.76 |