- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,772.85 / $3,772.85 / $3,817.28
| Facility | | $3,772.85 | $3,772.85 | $3,817.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.28 / $3,817.28 / $6,489.42
| Professional | | $3,817.28 | $3,817.28 | $6,489.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,399.81 / $25,969.67 / $34,937.53
| Facility | | $21,399.81 | $25,969.67 | $34,937.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.28 / $3,817.28 / $3,817.28
| Professional | | $3,817.28 | $3,817.28 | $3,817.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,817.28 / $3,817.28 / $3,817.28
| Facility | | $3,817.28 | $3,817.28 | $3,817.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.28 / $3,817.28 / $3,817.28
| Professional | | $3,817.28 | $3,817.28 | $3,817.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.28 / $3,817.28 / $4,046.32
| Professional | | $3,817.28 | $3,817.28 | $4,046.32 |