- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,408.38 / $18,201.90 / $24,527.40
| Facility | | $6,408.38 | $18,201.90 | $24,527.40 |
- 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 / $6,454.56
| Professional | | $6,408.38 | $6,408.38 | $6,454.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,045.64 / $6,045.64 / $6,408.38
| Facility | | $6,045.64 | $6,045.64 | $6,408.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,447.12 / $5,447.12 / $6,408.38
| Professional | | $5,447.12 | $5,447.12 | $6,408.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,831.63 / $6,408.38 / $10,386.57
| Professional | | $5,831.63 | $6,408.38 | $10,386.57 |