- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,361.56 / $10,361.56 / $10,361.56
| Facility | | $10,361.56 | $10,361.56 | $10,361.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,770.12 / $10,361.56 / $10,361.56
| Professional | | $8,770.12 | $10,361.56 | $10,361.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,461.32 / $54,713.54 / $99,651.36
| Facility | | $27,461.32 | $54,713.54 | $99,651.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,236.33 / $18,143.50 / $24,493.73
| Professional | | $17,236.33 | $18,143.50 | $24,493.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,257.05 / $11,625.41 / $11,793.28
| Facility | | $11,257.05 | $11,625.41 | $11,793.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,514.80 / $14,514.80 / $14,514.80
| Professional | | $14,514.80 | $14,514.80 | $14,514.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,736.82 / $11,736.82 / $11,736.82
| Facility | | $11,736.82 | $11,736.82 | $11,736.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,736.82 / $11,736.82 / $21,033.75
| Professional | | $11,736.82 | $11,736.82 | $21,033.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,361.56 / $13,111.33 / $13,111.33
| Facility | | $10,361.56 | $13,111.33 | $13,111.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,361.56 / $13,111.33 / $20,406.82
| Professional | | $10,361.56 | $13,111.33 | $20,406.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,412.26 / $13,426.19 / $15,440.11
| Professional | | $11,412.26 | $13,426.19 | $15,440.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,071.99 / $8,673.76 / $13,077.26
| Professional | | $7,071.99 | $8,673.76 | $13,077.26 |