- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,275.38 / $13,275.38 / $13,275.38
| Facility | | $13,275.38 | $13,275.38 | $13,275.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.46 / $13,275.38 / $14,357.40
| Professional | | $1,527.46 | $13,275.38 | $14,357.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,526.41 / $14,383.53 / $17,324.64
| Facility | | $11,526.41 | $14,383.53 | $17,324.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.46 / $13,275.38 / $14,357.40
| Professional | | $1,527.46 | $13,275.38 | $14,357.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,522.22 / $6,109.84 / $6,994.04
| Professional | | $5,522.22 | $6,109.84 | $6,994.04 |