- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,454.57 / $7,793.55 / $8,183.23
| Facility | | $6,454.57 | $7,793.55 | $8,183.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,408.38 / $6,600.63 / $8,183.23
| Professional | | $6,408.38 | $6,600.63 | $8,183.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,408.38 / $6,985.13 / $23,018.90
| Facility | | $6,408.38 | $6,985.13 | $23,018.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,408.38 / $6,408.38 / $8,010.48
| Professional | | $6,408.38 | $6,408.38 | $8,010.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,045.64 / $6,045.64 / $6,408.38
| Facility | | $6,045.64 | $6,045.64 | $6,408.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,408.38 / $6,408.38 / $6,408.38
| Professional | | $6,408.38 | $6,408.38 | $6,408.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,454.57 / $8,593.06 / $32,300.15
| Facility | | $6,454.57 | $8,593.06 | $32,300.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,486.38 / $6,454.57 / $7,422.76
| Professional | | $5,486.38 | $6,454.57 | $7,422.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,447.12 / $6,408.38 / $7,414.50
| Professional | | $5,447.12 | $6,408.38 | $7,414.50 |