- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,606.93 / $8,128.31
| Facility | | $5,623.41 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,248.07 / $8,511.38
| Professional | | $3,630.78 | $5,248.07 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Professional | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $7,079.46 / $8,511.38
| Professional | | $6,760.83 | $7,079.46 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $8,128.31 / $10,000.00
| Professional | | $7,413.10 | $8,128.31 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $6,760.83 / $10,000.00
| Professional | | $3,388.44 | $6,760.83 | $10,000.00 |