- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,664.71 / $10,045.10 / $17,908.20
| Facility | | $6,664.71 | $10,045.10 | $17,908.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,664.71 / $6,664.71 / $6,664.71
| Professional | | $6,664.71 | $6,664.71 | $6,664.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,408.38 / $9,742.02 / $19,883.91
| Facility | | $6,408.38 | $9,742.02 | $19,883.91 |
- 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
- $6,408.38 / $6,408.38 / $6,408.38
| Facility | | $6,408.38 | $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 / $6,650.20 / $8,016.52
| Professional | | $6,408.38 | $6,650.20 | $8,016.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,767.54 / $6,408.38 / $7,170.07
| Professional | | $5,767.54 | $6,408.38 | $7,170.07 |