- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,061.68 / $10,061.68 / $10,061.68
| Facility | | $10,061.68 | $10,061.68 | $10,061.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,110.20 / $10,061.68 / $10,061.68
| Professional | | $5,110.20 | $10,061.68 | $10,061.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,908.78 / $8,908.78 / $8,908.78
| Professional | | $8,908.78 | $8,908.78 | $8,908.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,121.18 / $8,121.18 / $12,554.20
| Facility | | $8,121.18 | $8,121.18 | $12,554.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,928.46 / $5,928.46 / $14,554.13
| Professional | | $5,928.46 | $5,928.46 | $14,554.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,980.97 / $5,971.46 / $9,201.83
| Professional | | $3,980.97 | $5,971.46 | $9,201.83 |