- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,408.38 / $9,100.94 / $17,685.50
| Facility | | $6,408.38 | $9,100.94 | $17,685.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,408.38 / $6,408.38 / $6,472.46
| Professional | | $6,408.38 | $6,408.38 | $6,472.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,045.64 / $6,683.37 / $8,649.07
| Facility | | $6,045.64 | $6,683.37 | $8,649.07 |
- 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
- $6,460.03 / $13,785.00 / $23,480.30
| Facility | | $6,460.03 | $13,785.00 | $23,480.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,193.29 / $6,454.57 / $6,624.52
| Professional | | $6,193.29 | $6,454.57 | $6,624.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,408.38 / $6,408.38 / $7,793.55
| Professional | | $6,408.38 | $6,408.38 | $7,793.55 |