- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,141.73 / $9,141.73 / $9,141.73
| Facility | | $9,141.73 | $9,141.73 | $9,141.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,141.73 / $9,141.73 / $10,779.06
| Professional | | $9,141.73 | $9,141.73 | $10,779.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,599.23 / $13,859.15 / $13,999.13
| Professional | | $12,599.23 | $13,859.15 | $13,999.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,418.01 / $15,768.62 / $15,768.62
| Facility | | $9,418.01 | $15,768.62 | $15,768.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,418.01 / $15,768.62 / $24,315.56
| Professional | | $9,418.01 | $15,768.62 | $24,315.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,294.08 / $15,691.04 / $74,662.03
| Facility | | $7,294.08 | $15,691.04 | $74,662.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,457.75 / $9,156.99 / $11,919.39
| Professional | | $5,457.75 | $9,156.99 | $11,919.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,722.49 / $15,768.62 / $21,777.21
| Facility | | $15,722.49 | $15,768.62 | $21,777.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,660.80 / $18,635.64 / $32,485.94
| Professional | | $13,660.80 | $18,635.64 | $32,485.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,164.85 / $7,164.85 / $7,164.85
| Facility | | $7,164.85 | $7,164.85 | $7,164.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,457.75 / $7,151.63 / $11,020.45
| Professional | | $5,457.75 | $7,151.63 | $11,020.45 |