- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,768.66 / $8,768.66 / $8,768.66
| Facility | | $8,768.66 | $8,768.66 | $8,768.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,832.96
| Professional | | $2,698.05 | $2,698.05 | $2,832.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,850.77
| Facility | | $2,698.05 | $2,698.05 | $2,850.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,698.05
| Professional | | $2,698.05 | $2,698.05 | $2,698.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,698.05
| Facility | | $2,698.05 | $2,698.05 | $2,698.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,698.05
| Professional | | $2,698.05 | $2,698.05 | $2,698.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $3,003.50
| Professional | | $2,698.05 | $2,698.05 | $3,003.50 |