- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,531.66 / $13,531.66 / $13,531.66
| Facility | | $13,531.66 | $13,531.66 | $13,531.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,156.60 / $13,531.66 / $13,531.66
| Professional | | $8,156.60 | $13,531.66 | $13,531.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,619.91 / $11,619.91 / $11,619.91
| Facility | | $11,619.91 | $11,619.91 | $11,619.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,619.91 / $11,619.91 / $11,619.91
| Professional | | $11,619.91 | $11,619.91 | $11,619.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $13,531.66 / $23,003.82
| Facility | | $100.00 | $13,531.66 | $23,003.82 |