- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,408.38 / $7,793.55 / $13,880.15
| Facility | | $6,408.38 | $7,793.55 | $13,880.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,408.38 / $6,472.46 / $7,916.70
| Professional | | $6,408.38 | $6,472.46 | $7,916.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,408.38 / $10,236.11 / $20,308.16
| Facility | | $6,408.38 | $10,236.11 | $20,308.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,408.38 / $6,408.38 / $6,454.57
| Professional | | $6,408.38 | $6,408.38 | $6,454.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,045.64 / $6,408.38 / $6,408.38
| Facility | | $6,045.64 | $6,408.38 | $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
- Professional
- Modifier
- Low / Median / High Price
- $6,408.38 / $6,408.38 / $7,049.22
| Professional | | $6,408.38 | $6,408.38 | $7,049.22 |