- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,734.20 / $9,734.20 / $9,734.20
| Facility | | $9,734.20 | $9,734.20 | $9,734.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,545.87 / $2,545.87
| Professional | | $2,396.11 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,645.71 / $2,795.46
| Facility | | $2,545.87 | $2,645.71 | $2,795.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,695.63 / $2,695.63 / $2,695.63
| Professional | | $2,695.63 | $2,695.63 | $2,695.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Facility | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Professional | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $2,495.94 / $2,778.52
| Professional | | $2,495.94 | $2,495.94 | $2,778.52 |