- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,489.63 / $13,489.63 / $13,489.63
| Facility | | $13,489.63 | $13,489.63 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $13,489.63 / $16,218.10
| Professional | | $8,128.31 | $13,489.63 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $10,232.93
| Professional | | $6,606.93 | $6,606.93 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Facility | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $11,748.98 / $12,022.64
| Professional | | $9,772.37 | $11,748.98 | $12,022.64 |