- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,155.72 / $11,155.72 / $11,155.72
| Facility | | $11,155.72 | $11,155.72 | $11,155.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.58 / $11,155.72 / $12,064.92
| Professional | | $1,283.58 | $11,155.72 | $12,064.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,686.09 / $11,505.78 / $14,558.40
| Facility | | $9,686.09 | $11,505.78 | $14,558.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.58 / $11,155.72 / $12,064.92
| Professional | | $1,283.58 | $11,155.72 | $12,064.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,640.52 / $5,134.32 / $5,877.36
| Professional | | $4,640.52 | $5,134.32 | $5,877.36 |