- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,023.56 / $7,023.56 / $7,023.56
| Facility | | $7,023.56 | $7,023.56 | $7,023.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,567.18 / $7,023.56 / $7,023.56
| Professional | | $3,567.18 | $7,023.56 | $7,023.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,751.45 / $4,751.45 / $8,612.66
| Facility | | $4,751.45 | $4,751.45 | $8,612.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,038.73 / $4,751.45 / $7,541.55
| Professional | | $4,038.73 | $4,751.45 | $7,541.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.05 / $4,168.38 / $5,903.77
| Professional | | $2,529.05 | $4,168.38 | $5,903.77 |