- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $8,128.31 / $12,022.64
| Professional | | $6,606.93 | $8,128.31 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $10,715.19
| Professional | | $9,772.37 | $9,772.37 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $10,715.19
| Professional | | $10,715.19 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $22,908.68 / $23,988.33
| Professional | | $10,000.00 | $22,908.68 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $7,943.28 / $13,182.57
| Professional | | $5,248.07 | $7,943.28 | $13,182.57 |