- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,064.26 / $9,064.26 / $9,064.26
| Facility | | $9,064.26 | $9,064.26 | $9,064.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,603.63 / $9,064.26 / $9,064.26
| Professional | | $4,603.63 | $9,064.26 | $9,064.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,025.65 / $8,025.65 / $8,025.65
| Professional | | $8,025.65 | $8,025.65 | $8,025.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,261.93 / $7,261.93 / $10,803.79
| Facility | | $7,261.93 | $7,261.93 | $10,803.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,301.21 / $5,301.21 / $12,525.00
| Professional | | $5,301.21 | $5,301.21 | $12,525.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,075.66 / $5,379.50 / $7,366.55
| Professional | | $3,075.66 | $5,379.50 | $7,366.55 |