- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,121.26 / $8,121.26 / $15,531.90
| Facility | | $8,121.26 | $8,121.26 | $15,531.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,121.26 / $8,425.81 / $10,151.58
| Professional | | $8,121.26 | $8,425.81 | $10,151.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,882.64 / $8,927.04 / $9,041.64
| Facility | | $8,882.64 | $8,927.04 | $9,041.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,576.67 / $8,927.04 / $9,041.64
| Professional | | $7,576.67 | $8,927.04 | $9,041.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.38 / $559.22 / $8,628.84
| Professional | | $447.38 | $559.22 | $8,628.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $434.25 / $7,821.20 / $10,557.64
| Facility | | $434.25 | $7,821.20 | $10,557.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,459.66 / $9,417.37 / $37,127.98
| Professional | | $8,459.66 | $9,417.37 | $37,127.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,459.66 / $8,459.66 / $10,151.58
| Professional | | $8,459.66 | $8,459.66 | $10,151.58 |