- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,484.91 / $8,484.91 / $8,484.91
| Facility | | $8,484.91 | $8,484.91 | $8,484.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,254.06 / $7,984.60 / $8,484.91
| Professional | | $4,254.06 | $7,984.60 | $8,484.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,677.75 / $10,130.04 / $14,105.81
| Facility | | $8,677.75 | $10,130.04 | $14,105.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,104.04 / $9,623.54 / $10,130.04
| Professional | | $8,104.04 | $9,623.54 | $10,130.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,553.03 / $31,255.82 / $86,810.41
| Facility | | $6,553.03 | $31,255.82 | $86,810.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,743.88 / $12,448.51 / $14,914.72
| Professional | | $11,743.88 | $12,448.51 | $14,914.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,556.21 / $29,988.43 / $68,354.64
| Facility | | $18,556.21 | $29,988.43 | $68,354.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,743.88 / $11,743.88 / $12,084.80
| Professional | | $11,743.88 | $11,743.88 | $12,084.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,007.91 / $10,130.04 / $46,975.22
| Facility | | $3,007.91 | $10,130.04 | $46,975.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,015.68 / $5,051.26 / $10,172.40
| Professional | | $3,015.68 | $5,051.26 | $10,172.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,015.68 / $5,053.77 / $13,675.57
| Professional | | $3,015.68 | $5,053.77 | $13,675.57 |