- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,589.25 / $13,803.84 / $19,952.62
| Professional | | $12,589.25 | $13,803.84 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,182.57 / $13,182.57 / $13,182.57
| Facility | | $13,182.57 | $13,182.57 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,964.78 / $10,964.78 / $13,489.63
| Professional | | $10,964.78 | $10,964.78 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $23,988.33
| Facility | | $6,760.83 | $6,760.83 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,748.98 / $21,877.62 / $21,877.62
| Professional | | $11,748.98 | $21,877.62 | $21,877.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $19,952.62 / $19,952.62
| Facility | | $19,952.62 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,952.62 / $19,952.62 / $19,952.62
| Professional | | $19,952.62 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $23,988.33
| Facility | | $6,760.83 | $6,760.83 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $13,182.57 / $21,379.62
| Professional | | $60.26 | $13,182.57 | $21,379.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $13,803.84 / $15,848.93
| Facility | | $13,803.84 | $13,803.84 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $13,803.84 / $50,118.72
| Professional | | $13,489.63 | $13,803.84 | $50,118.72 |