- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,961.61 / $7,961.62 / $13,251.74
| Facility | | $7,961.61 | $7,961.62 | $13,251.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,961.62 / $7,961.62 / $7,961.62
| Professional | | $7,961.62 | $7,961.62 | $7,961.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,493.06 / $2,164.52 / $3,798.60
| Facility | | $1,493.06 | $2,164.52 | $3,798.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,165.46 / $7,961.62 / $13,932.84
| Facility | | $7,165.46 | $7,961.62 | $13,932.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,775.00 / $3,775.00 / $5,256.46
| Professional | | $3,775.00 | $3,775.00 | $5,256.46 |