- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,285.74 / $8,285.74 / $8,285.74
| Facility | | $8,285.74 | $8,285.74 | $8,285.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,208.22 / $8,285.74 / $8,285.74
| Professional | | $4,208.22 | $8,285.74 | $8,285.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,957.05 / $7,957.05 / $10,147.12
| Facility | | $7,957.05 | $7,957.05 | $10,147.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,763.49 / $7,957.05 / $9,381.87
| Professional | | $6,763.49 | $7,957.05 | $9,381.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,147.53 / $10,147.53 / $11,938.27
| Facility | | $10,147.53 | $10,147.53 | $11,938.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,977.94 / $4,917.46 / $6,883.36
| Professional | | $2,977.94 | $4,917.46 | $6,883.36 |