- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $6,606.93
| Facility | | $5,754.40 | $5,754.40 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,265.80 / $6,606.93
| Professional | | $3,388.44 | $4,265.80 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $8,709.64 / $9,549.93
| Professional | | $6,606.93 | $8,709.64 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $11,481.54
| Professional | | $9,120.11 | $9,120.11 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $6,606.93 / $33,884.42
| Facility | | $3,467.37 | $6,606.93 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,981.07 / $7,943.28
| Professional | | $3,162.28 | $3,981.07 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,786.30 / $8,511.38
| Professional | | $2,754.23 | $4,786.30 | $8,511.38 |