- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,232.30 / $15,232.30 / $15,232.30
| Facility | | $15,232.30 | $15,232.30 | $15,232.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $4,874.33
| Professional | | $4,686.85 | $4,686.85 | $4,874.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,672.47 / $4,672.47 / $4,936.95
| Facility | | $4,672.47 | $4,672.47 | $4,936.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $4,686.85
| Professional | | $4,686.85 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,421.56 / $4,686.85 / $4,686.85
| Facility | | $4,421.56 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $4,686.85
| Professional | | $4,686.85 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $4,686.85
| Professional | | $4,686.85 | $4,686.85 | $4,686.85 |