- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $8,128.31
| Facility | | $6,760.83 | $6,760.83 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,165.95 / $10,715.19
| Professional | | $5,248.07 | $6,165.95 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $13,182.57 / $14,791.08
| Facility | | $12,302.69 | $13,182.57 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Professional | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,709.64
| Facility | | $8,128.31 | $8,128.31 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $8,128.31
| Professional | | $5,888.44 | $5,888.44 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $18,197.01
| Professional | | $10,471.29 | $10,471.29 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,943.28 / $8,912.51
| Facility | | $3,715.35 | $7,943.28 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,456.54 / $10,471.29
| Professional | | $4,677.35 | $6,456.54 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $16,982.44
| Facility | | $10,715.19 | $10,715.19 | $16,982.44 |