- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,488.17 / $16,218.10 / $16,218.10
| Facility | | $15,488.17 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $14,125.38 / $20,417.38
| Professional | | $9,549.93 | $14,125.38 | $20,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $12,589.25 / $20,417.38
| Facility | | $12,589.25 | $12,589.25 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,387.21 / $22,387.21 / $28,183.83
| Professional | | $22,387.21 | $22,387.21 | $28,183.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $20,417.38 / $56,234.13
| Facility | | $16,595.87 | $20,417.38 | $56,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $13,489.63 / $114,815.36
| Professional | | $8,317.64 | $13,489.63 | $114,815.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,595.87 / $19,952.62 / $19,952.62
| Professional | | $16,595.87 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,417.38 / $20,417.38 / $20,417.38
| Facility | | $20,417.38 | $20,417.38 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $38,018.94
| Professional | | $16,595.87 | $16,595.87 | $38,018.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,782.79 / $21,379.62 / $28,183.83
| Professional | | $17,782.79 | $21,379.62 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $13,182.57 / $20,892.96
| Professional | | $7,762.47 | $13,182.57 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,782.79 / $17,782.79 / $17,782.79
| Professional | | $17,782.79 | $17,782.79 | $17,782.79 |