- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,421.86 / $8,421.86 / $8,421.86
| Facility | | $8,421.86 | $8,421.86 | $8,421.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,073.07 / $2,073.07 / $2,202.64
| Professional | | $2,073.07 | $2,073.07 | $2,202.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,202.64 / $2,289.02 / $2,418.58
| Facility | | $2,202.64 | $2,289.02 | $2,418.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,332.21 / $2,332.21 / $2,332.21
| Professional | | $2,332.21 | $2,332.21 | $2,332.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,202.64 / $2,202.64 / $2,202.64
| Facility | | $2,202.64 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,202.64 / $2,202.64 / $2,202.64
| Professional | | $2,202.64 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.44 / $2,159.44 / $2,159.44
| Professional | | $2,159.44 | $2,159.44 | $2,159.44 |