- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $13,489.63 / $16,595.87
| Facility | | $9,772.37 | $13,489.63 | $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
- $13,489.63 / $13,489.63 / $13,489.63
| Facility | | $13,489.63 | $13,489.63 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |