- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,106.75 / $3,106.75 / $3,106.75
| Facility | | $3,106.75 | $3,106.75 | $3,106.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,997.10 / $3,106.75 / $5,166.31
| Professional | | $2,997.10 | $3,106.75 | $5,166.31 |
- 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
- $3,045.83 / $3,045.83 / $3,045.83
| Professional | | $3,045.83 | $3,045.83 | $3,045.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.26 / $3,146.26 / $3,146.26
| Facility | | $3,146.26 | $3,146.26 | $3,146.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,045.83 / $3,045.83 / $3,045.83
| Professional | | $3,045.83 | $3,045.83 | $3,045.83 |