- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,553.37 / $6,553.37 / $6,553.37
| Facility | | $6,553.37 | $6,553.37 | $6,553.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,097.08
| Professional | | $2,016.42 | $2,016.42 | $2,097.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,976.55 / $1,976.55 / $2,159.69
| Facility | | $1,976.55 | $1,976.55 | $2,159.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.29 / $2,016.42 / $2,016.42
| Facility | | $1,902.29 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |