- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,060.17 / $2,060.17 / $2,060.17
| Facility | | $2,060.17 | $2,060.17 | $2,060.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,060.17 / $2,060.17 / $2,144.02
| Professional | | $2,060.17 | $2,060.17 | $2,144.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,871.43 / $3,453.21 / $4,166.59
| Professional | | $2,871.43 | $3,453.21 | $4,166.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,733.34 / $3,212.42 / $3,623.39
| Facility | | $2,733.34 | $3,212.42 | $3,623.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.59 / $3,737.82 / $16,324.48
| Professional | | $2,123.59 | $3,737.82 | $16,324.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,531.65 / $3,213.25 / $4,581.92
| Facility | | $2,531.65 | $3,213.25 | $4,581.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,213.25 / $4,166.59 / $4,581.92
| Professional | | $3,213.25 | $4,166.59 | $4,581.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.59 / $3,497.78 / $5,260.89
| Professional | | $2,123.59 | $3,497.78 | $5,260.89 |