- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,036.45 / $2,036.45 / $4,338.00
| Facility | | $2,036.45 | $2,036.45 | $4,338.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,938.15 / $2,036.45 / $2,101.23
| Professional | | $1,938.15 | $2,036.45 | $2,101.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,234.86 / $3,441.60 / $4,202.46
| Facility | | $2,234.86 | $3,441.60 | $4,202.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,296.79 / $4,304.96 / $16,382.08
| Professional | | $2,296.79 | $4,304.96 | $16,382.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,527.44 / $2,811.63 / $4,056.68
| Facility | | $2,527.44 | $2,811.63 | $4,056.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,811.63 / $2,811.63 / $11,142.88
| Professional | | $2,811.63 | $2,811.63 | $11,142.88 |
- 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
- $2,177.57 / $3,885.07 / $6,043.44
| Professional | | $2,177.57 | $3,885.07 | $6,043.44 |