- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,967.45 / $9,967.45 / $75,852.00
| Facility | | $9,967.45 | $9,967.45 | $75,852.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,967.45 / $11,391.37 / $11,391.37
| Professional | | $9,967.45 | $11,391.37 | $11,391.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,034.23 / $13,034.23 / $13,034.23
| Facility | | $13,034.23 | $13,034.23 | $13,034.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,079.10 / $13,034.23 / $13,034.23
| Professional | | $11,079.10 | $13,034.23 | $13,034.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,718.30 / $13,952.53 / $100,282.95
| Facility | | $6,718.30 | $13,952.53 | $100,282.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,937.71 / $13,751.66 / $22,686.36
| Professional | | $6,937.71 | $13,751.66 | $22,686.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,937.71 / $11,072.91 / $15,676.03
| Professional | | $6,937.71 | $11,072.91 | $15,676.03 |