- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,753.05 / $11,753.05 / $11,753.05
| Facility | | $11,753.05 | $11,753.05 | $11,753.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,908.03 / $11,753.05 / $11,884.36
| Professional | | $5,908.03 | $11,753.05 | $11,884.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,020.17 / $14,031.86 / $19,538.96
| Facility | | $12,020.17 | $14,031.86 | $19,538.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,225.49 / $13,330.27 / $14,031.86
| Professional | | $11,225.49 | $13,330.27 | $14,031.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,077.06 / $43,294.88 / $120,247.87
| Facility | | $9,077.06 | $43,294.88 | $120,247.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,267.13 / $17,243.15 / $20,659.25
| Professional | | $16,267.13 | $17,243.15 | $20,659.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,703.66 / $41,539.32 / $94,683.36
| Facility | | $25,703.66 | $41,539.32 | $94,683.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,267.13 / $16,267.13 / $16,739.59
| Professional | | $16,267.13 | $16,267.13 | $16,739.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,064.14 / $14,031.86 / $63,807.96
| Facility | | $4,064.14 | $14,031.86 | $63,807.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,074.64 / $6,835.20 / $14,090.53
| Professional | | $4,074.64 | $6,835.20 | $14,090.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,074.64 / $6,111.95 / $14,090.53
| Professional | | $4,074.64 | $6,111.95 | $14,090.53 |