- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,760.83 / $8,511.38
| Facility | | $4,365.16 | $6,760.83 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $6,760.83
| Professional | | $3,890.45 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $16,595.87 / $28,840.32
| Facility | | $9,120.11 | $16,595.87 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,135.61 / $15,135.61 / $15,135.61
| Professional | | $15,135.61 | $15,135.61 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,495.41 / $8,511.38
| Facility | | $3,890.45 | $5,495.41 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $6,760.83
| Professional | | $3,801.89 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $20,892.96 / $29,512.09
| Facility | | $15,848.93 | $20,892.96 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $21,877.62 / $24,547.09
| Professional | | $8,317.64 | $21,877.62 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $26,915.35 / $29,512.09
| Facility | | $11,748.98 | $26,915.35 | $29,512.09 |