- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $12,302.69 / $12,302.69
| Facility | | $12,302.69 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $11,220.18 / $13,803.84
| Professional | | $6,918.31 | $11,220.18 | $13,803.84 |
- 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
- $16,982.44 / $16,982.44 / $20,892.96
| Professional | | $16,982.44 | $16,982.44 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $18,620.87 / $51,286.14
| Facility | | $12,302.69 | $18,620.87 | $51,286.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,964.78 / $95,499.26
| Professional | | $6,606.93 | $10,964.78 | $95,499.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,182.57 / $15,848.93 / $15,848.93
| Professional | | $13,182.57 | $15,848.93 | $15,848.93 |
- 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
- $13,182.57 / $13,182.57 / $33,884.42
| Professional | | $13,182.57 | $13,182.57 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,848.93 / $19,054.61 / $25,118.86
| Professional | | $15,848.93 | $19,054.61 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $10,715.19 / $15,848.93
| Professional | | $5,754.40 | $10,715.19 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,125.38 / $14,125.38 / $14,125.38
| Professional | | $14,125.38 | $14,125.38 | $14,125.38 |