- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $8,317.64 / $10,232.93
| Facility | | $6,918.31 | $8,317.64 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,888.44 / $10,715.19
| Professional | | $4,570.88 | $5,888.44 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $10,232.93
| Professional | | $10,232.93 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,912.51 / $10,471.29
| Professional | | $8,511.38 | $8,912.51 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $10,232.93 / $12,589.25
| Professional | | $9,332.54 | $10,232.93 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,715.35 / $10,232.93
| Professional | | $1,819.70 | $3,715.35 | $10,232.93 |