- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $2,440.69
| Facility | | $2,429.89 | $2,429.89 | $2,440.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $2,915.87
| Professional | | $2,429.89 | $2,429.89 | $2,915.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,399.81 / $25,969.67 / $34,937.53
| Facility | | $21,399.81 | $25,969.67 | $34,937.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $2,429.89
| Professional | | $2,429.89 | $2,429.89 | $2,429.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $2,429.89
| Facility | | $2,429.89 | $2,429.89 | $2,429.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $2,974.42
| Professional | | $2,429.89 | $2,429.89 | $2,974.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.41 / $2,429.89 / $2,704.98
| Professional | | $2,065.41 | $2,429.89 | $2,704.98 |