- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Facility | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $9,549.93 / $61,659.50
| Professional | | $7,585.78 | $9,549.93 | $61,659.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,589.25 / $13,803.84 / $14,125.38
| Professional | | $12,589.25 | $13,803.84 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $16,218.10
| Facility | | $9,332.54 | $9,332.54 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $16,982.44 / $27,542.29
| Professional | | $9,332.54 | $16,982.44 | $27,542.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $15,848.93 / $74,131.02
| Facility | | $9,120.11 | $15,848.93 | $74,131.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $8,912.51 / $14,454.40
| Professional | | $4,786.30 | $8,912.51 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,848.93 / $15,848.93 / $35,481.34
| Professional | | $15,848.93 | $15,848.93 | $35,481.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,218.10
| Facility | | $16,218.10 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,952.62 / $35,481.34 / $35,481.34
| Professional | | $19,952.62 | $35,481.34 | $35,481.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,715.19 / $16,595.87
| Facility | | $6,456.54 | $10,715.19 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,079.46 / $11,220.18
| Professional | | $5,495.41 | $7,079.46 | $11,220.18 |