- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,454.57 / $6,970.93 / $11,850.60
| Facility | | $6,454.57 | $6,970.93 | $11,850.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,921.05 / $6,921.05 / $6,921.05
| Professional | | $6,921.05 | $6,921.05 | $6,921.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,252.85 / $6,773.92 / $10,674.83
| Facility | | $4,252.85 | $6,773.92 | $10,674.83 |
- 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
- $196.72 / $6,408.38 / $6,408.38
| Professional | | $196.72 | $6,408.38 | $6,408.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,594.42 / $6,970.93 / $9,968.43
| Facility | | $5,594.42 | $6,970.93 | $9,968.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,408.38 / $6,454.57 / $6,460.03
| Professional | | $6,408.38 | $6,454.57 | $6,460.03 |
- 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 |