- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,828.16 / $12,828.16 / $12,828.16
| Facility | | $12,828.16 | $12,828.16 | $12,828.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,455.84 / $12,828.16 / $14,025.20
| Professional | | $7,455.84 | $12,828.16 | $14,025.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,119.71 / $15,315.43 / $21,326.29
| Facility | | $13,119.71 | $15,315.43 | $21,326.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,252.34 / $14,549.66 / $15,315.43
| Professional | | $12,252.34 | $14,549.66 | $15,315.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,907.40 / $47,255.14 / $131,247.15
| Facility | | $9,907.40 | $47,255.14 | $131,247.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,755.13 / $18,820.43 / $22,549.01
| Professional | | $17,755.13 | $18,820.43 | $22,549.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,054.81 / $45,338.99 / $103,344.21
| Facility | | $28,054.81 | $45,338.99 | $103,344.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,755.13 / $17,755.13 / $18,270.80
| Professional | | $17,755.13 | $17,755.13 | $18,270.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,796.26 / $15,315.43 / $75,302.32
| Facility | | $4,796.26 | $15,315.43 | $75,302.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,808.64 / $8,036.74 / $15,590.11
| Professional | | $4,808.64 | $8,036.74 | $15,590.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,808.64 / $8,054.47 / $19,910.06
| Professional | | $4,808.64 | $8,054.47 | $19,910.06 |