- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,897.70 / $11,897.70 / $11,897.70
| Facility | | $11,897.70 | $11,897.70 | $11,897.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,807.27
| Professional | | $3,660.83 | $3,660.83 | $3,807.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,638.86 / $3,638.86 / $3,919.73
| Facility | | $3,638.86 | $3,638.86 | $3,919.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,660.83
| Professional | | $3,660.83 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,453.62 / $3,660.83 / $3,660.83
| Facility | | $3,453.62 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,660.83
| Professional | | $3,660.83 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,660.83
| Professional | | $3,660.83 | $3,660.83 | $3,660.83 |