- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,491.56 / $8,491.56 / $11,726.40
| Facility | | $8,491.56 | $8,491.56 | $11,726.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,043.60 / $8,019.80 / $8,491.56
| Professional | | $4,043.60 | $8,019.80 | $8,491.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,380.56 / $5,081.45 / $10,075.29
| Facility | | $4,380.56 | $5,081.45 | $10,075.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,065.40 / $6,065.40 / $6,065.40
| Facility | | $6,065.40 | $6,065.40 | $6,065.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,830.52 / $4,043.60 / $6,739.33
| Professional | | $2,830.52 | $4,043.60 | $6,739.33 |