- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,816.23 / $10,816.23 / $10,816.23
| Facility | | $10,816.23 | $10,816.23 | $10,816.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,493.43 / $10,816.23 / $10,816.23
| Professional | | $5,493.43 | $10,816.23 | $10,816.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,576.87 / $9,576.87 / $9,576.87
| Professional | | $9,576.87 | $9,576.87 | $9,576.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,077.06 / $9,077.06 / $14,031.86
| Facility | | $9,077.06 | $9,077.06 | $14,031.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,626.25 / $9,077.06 / $12,286.79
| Professional | | $6,626.25 | $9,077.06 | $12,286.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,074.64 / $6,419.27 / $9,418.33
| Professional | | $4,074.64 | $6,419.27 | $9,418.33 |