- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $12,022.64 / $16,595.87
| Facility | | $8,709.64 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,125.38 / $14,125.38 / $16,595.87
| Professional | | $14,125.38 | $14,125.38 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Facility | | $8,709.64 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $645.65
| Professional | | $60.26 | $60.26 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |