- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,200.58 / $14,200.58 / $14,200.58
| Facility | | $14,200.58 | $14,200.58 | $14,200.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $5,210.58
| Professional | | $5,210.58 | $5,210.58 | $5,210.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,928.70 / $1,928.70 / $2,893.05
| Facility | | $1,928.70 | $1,928.70 | $2,893.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $5,210.58
| Facility | | $5,210.58 | $5,210.58 | $5,210.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $7,414.49
| Professional | | $5,210.58 | $5,210.58 | $7,414.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $5,108.41 / $7,398.51
| Professional | | $5,108.41 | $5,108.41 | $7,398.51 |