- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,050.93 / $6,050.93 / $6,520.40
| Facility | | $6,050.93 | $6,050.93 | $6,520.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,712.48 / $3,078.11
| Professional | | $2,608.16 | $2,712.48 | $3,078.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,319.69 / $2,899.49 / $8,265.26
| Facility | | $2,319.69 | $2,899.49 | $8,265.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,706.58
| Professional | | $2,608.16 | $2,608.16 | $2,706.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $3,010.31
| Facility | | $2,608.16 | $2,608.16 | $3,010.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,608.16
| Professional | | $2,608.16 | $2,608.16 | $2,608.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,608.16
| Professional | | $2,608.16 | $2,608.16 | $2,608.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,050.93 / $6,050.93 / $6,520.40
| Facility | | $6,050.93 | $6,050.93 | $6,520.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,738.56 / $4,273.72
| Professional | | $2,608.16 | $2,738.56 | $4,273.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $3,781.83
| Professional | | $2,608.16 | $2,608.16 | $3,781.83 |