- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Facility | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $9,549.93 / $11,748.98
| Professional | | $5,888.44 | $9,549.93 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $13,803.84
| Facility | | $9,120.11 | $9,120.11 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $20,417.38
| Professional | | $16,218.10 | $16,218.10 | $20,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $15,848.93 / $43,651.58
| Facility | | $10,715.19 | $15,848.93 | $43,651.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $9,332.54 / $81,283.05
| Professional | | $5,623.41 | $9,332.54 | $81,283.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $13,489.63 / $13,489.63
| Professional | | $11,220.18 | $13,489.63 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $13,803.84 / $13,803.84
| Facility | | $13,803.84 | $13,803.84 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $29,512.09
| Professional | | $11,220.18 | $11,220.18 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $16,218.10 / $21,379.62
| Professional | | $13,489.63 | $16,218.10 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $9,120.11 / $14,454.40
| Professional | | $5,623.41 | $9,120.11 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,022.64 / $12,022.64 / $12,022.64
| Professional | | $12,022.64 | $12,022.64 | $12,022.64 |