- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,694.63 / $10,694.63 / $10,694.63
| Facility | | $10,694.63 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.51 / $10,694.63 / $11,566.32
| Professional | | $1,230.51 | $10,694.63 | $11,566.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,285.70 / $11,029.28 / $13,956.64
| Facility | | $9,285.70 | $11,029.28 | $13,956.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.51 / $10,694.63 / $11,566.32
| Professional | | $1,230.51 | $10,694.63 | $11,566.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,448.70 / $4,922.04 / $8,203.40
| Professional | | $4,448.70 | $4,922.04 | $8,203.40 |