- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,289.00 / $7,546.80 / $7,546.80
| Facility | | $6,289.00 | $7,546.80 | $7,546.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,534.32 / $7,546.80 / $8,804.60
| Facility | | $5,534.32 | $7,546.80 | $8,804.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,037.44 / $6,037.44 / $6,792.12
| Professional | | $6,037.44 | $6,037.44 | $6,792.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,087.85 / $6,037.44 / $15,092.34
| Facility | | $4,087.85 | $6,037.44 | $15,092.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24,250.38 / $24,250.38 / $24,250.38
| Professional | | $24,250.38 | $24,250.38 | $24,250.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.10 / $2,515.60 / $7,295.24
| Professional | | $2,113.10 | $2,515.60 | $7,295.24 |