- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,204.92 / $9,204.92 / $9,204.92
| Facility | | $9,204.92 | $9,204.92 | $9,204.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,675.07 / $9,204.92 / $9,204.92
| Professional | | $4,675.07 | $9,204.92 | $9,204.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,150.19 / $8,150.19 / $8,150.19
| Professional | | $8,150.19 | $8,150.19 | $8,150.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,503.37 / $7,503.37 / $10,753.02
| Facility | | $7,503.37 | $7,503.37 | $10,753.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $7,503.37 / $9,415.71
| Professional | | $5,477.46 | $7,503.37 | $9,415.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,133.24 / $5,462.98 / $7,504.46
| Professional | | $3,133.24 | $5,462.98 | $7,504.46 |