- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Facility | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,309.57 / $8,317.64
| Professional | | $5,011.87 | $6,309.57 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $8,317.64
| Professional | | $6,309.57 | $6,309.57 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Facility | | $8,709.64 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $8,912.51
| Professional | | $6,309.57 | $6,309.57 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,943.28 / $16,982.44 / $23,442.29
| Professional | | $7,943.28 | $16,982.44 | $23,442.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,197.01 / $18,197.01 / $18,197.01
| Facility | | $18,197.01 | $18,197.01 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,025.60 / $8,912.51
| Professional | | $3,981.07 | $6,025.60 | $8,912.51 |