- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,185.37 / $12,185.37 / $12,185.37
| Facility | | $12,185.37 | $12,185.37 | $12,185.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,505.56 / $12,185.37 / $12,185.37
| Professional | | $6,505.56 | $12,185.37 | $12,185.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,458.14 / $10,458.14 / $10,458.14
| Professional | | $10,458.14 | $10,458.14 | $10,458.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.81 / $10,777.03 / $22,406.25
| Professional | | $1,092.81 | $10,777.03 | $22,406.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,338.26 / $5,785.07 / $10,303.37
| Professional | | $4,338.26 | $5,785.07 | $10,303.37 |