- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,050.24 / $12,050.24 / $12,050.24
| Facility | | $12,050.24 | $12,050.24 | $12,050.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,120.16 / $12,050.24 / $12,050.24
| Professional | | $6,120.16 | $12,050.24 | $12,050.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,669.48 / $10,669.48 / $10,669.48
| Professional | | $10,669.48 | $10,669.48 | $10,669.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,418.01 / $9,418.01 / $14,558.92
| Facility | | $9,418.01 | $9,418.01 | $14,558.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,875.15 / $9,418.01 / $12,748.31
| Professional | | $6,875.15 | $9,418.01 | $12,748.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,164.85 / $7,164.85 / $7,164.85
| Facility | | $7,164.85 | $7,164.85 | $7,164.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,767.76 / $7,151.63 / $11,020.45
| Professional | | $4,767.76 | $7,151.63 | $11,020.45 |