- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,798.34 / $19,798.34 / $19,798.34
| Facility | | $19,798.34 | $19,798.34 | $19,798.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,773.45 / $19,798.34 / $22,756.18
| Professional | | $17,773.45 | $19,798.34 | $22,756.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,034.23 / $13,034.23 / $25,049.43
| Facility | | $13,034.23 | $13,034.23 | $25,049.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,402.38 / $27,402.38 / $34,252.97
| Professional | | $27,402.38 | $27,402.38 | $34,252.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,766.75 / $38,457.94 / $100,282.95
| Facility | | $20,766.75 | $38,457.94 | $100,282.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,283.34 / $15,500.37 / $26,031.40
| Professional | | $9,283.34 | $15,500.37 | $26,031.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,828.15 / $25,049.43 / $40,029.96
| Facility | | $20,828.15 | $25,049.43 | $40,029.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,515.61 / $25,402.00 / $47,868.96
| Professional | | $20,515.61 | $25,402.00 | $47,868.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,437.25 / $22,756.18 / $27,049.34
| Professional | | $19,437.25 | $22,756.18 | $27,049.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,148.24 / $13,875.42 / $19,375.46
| Professional | | $8,148.24 | $13,875.42 | $19,375.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,772.21 / $22,772.21 / $22,772.21
| Professional | | $22,772.21 | $22,772.21 | $22,772.21 |