- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,406.20 / $12,406.20 / $12,406.20
| Facility | | $12,406.20 | $12,406.20 | $12,406.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.28 / $3,817.28 / $3,969.97
| Professional | | $3,817.28 | $3,817.28 | $3,969.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,772.85 / $3,772.85 / $3,986.41
| Facility | | $3,772.85 | $3,772.85 | $3,986.41 |
- 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
- $3,601.20 / $3,817.28 / $3,817.28
| Facility | | $3,601.20 | $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 / $4,046.32 / $4,249.43
| Professional | | $3,817.28 | $4,046.32 | $4,249.43 |