- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,102.62 / $10,102.62 / $10,102.62
| Facility | | $10,102.62 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.40 / $10,102.62 / $10,926.12
| Professional | | $1,162.40 | $10,102.62 | $10,926.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,771.69 / $10,420.65 / $13,184.16
| Facility | | $8,771.69 | $10,420.65 | $13,184.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.40 / $10,102.62 / $10,926.12
| Professional | | $1,162.40 | $10,102.62 | $10,926.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,202.46 / $4,649.60 / $7,749.33
| Professional | | $4,202.46 | $4,649.60 | $7,749.33 |