- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,733.35 / $6,733.35 / $6,733.35
| Facility | | $6,733.35 | $6,733.35 | $6,733.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,419.79 / $6,733.35 / $6,733.35
| Professional | | $3,419.79 | $6,733.35 | $6,733.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,961.82 / $5,961.82 / $5,961.82
| Professional | | $5,961.82 | $5,961.82 | $5,961.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,541.83 / $6,541.83 / $10,112.75
| Facility | | $6,541.83 | $6,541.83 | $10,112.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.54 / $6,541.83 / $8,855.08
| Professional | | $4,775.54 | $6,541.83 | $8,855.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,078.09 / $9,078.09 / $10,680.11
| Facility | | $9,078.09 | $9,078.09 | $10,680.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,664.10 / $4,213.74 / $6,380.81
| Professional | | $2,664.10 | $4,213.74 | $6,380.81 |