- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,103.41 / $2,103.41 / $4,338.00
| Facility | | $2,103.41 | $2,103.41 | $4,338.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.89 / $2,103.41 / $2,171.07
| Professional | | $2,001.89 | $2,103.41 | $2,171.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,308.48 / $3,554.76 / $4,342.14
| Facility | | $2,308.48 | $3,554.76 | $4,342.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,372.75 / $4,447.28 / $16,926.72
| Professional | | $2,372.75 | $4,447.28 | $16,926.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,610.83 / $2,905.11 / $4,191.47
| Facility | | $2,610.83 | $2,905.11 | $4,191.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,905.11 / $2,905.11 / $11,510.48
| Professional | | $2,905.11 | $2,905.11 | $11,510.48 |
- 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
- $2,446.00 / $4,013.51 / $6,243.24
| Professional | | $2,446.00 | $4,013.51 | $6,243.24 |