- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,788.21 / $7,788.21 / $7,788.21
| Facility | | $7,788.21 | $7,788.21 | $7,788.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,955.53 / $7,788.21 / $7,788.21
| Professional | | $3,955.53 | $7,788.21 | $7,788.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,895.81 / $6,895.81 / $6,895.81
| Professional | | $6,895.81 | $6,895.81 | $6,895.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,553.03 / $6,553.03 / $10,130.04
| Facility | | $6,553.03 | $6,553.03 | $10,130.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,783.71 / $6,553.03 / $8,870.23
| Professional | | $4,783.71 | $6,553.03 | $8,870.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,015.68 / $4,622.18 / $6,970.60
| Professional | | $3,015.68 | $4,622.18 | $6,970.60 |