- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,056.00 / $3,020.42 / $4,933.00
| Facility | | $2,056.00 | $3,020.42 | $4,933.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,907.31 / $3,020.42 / $3,020.42
| Professional | | $1,907.31 | $3,020.42 | $3,020.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.54 / $1,514.92 / $1,514.92
| Facility | | $257.54 | $1,514.92 | $1,514.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.83 / $1,439.17 / $2,045.14
| Professional | | $267.83 | $1,439.17 | $2,045.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,056.00 / $3,020.42 / $4,933.00
| Facility | | $2,056.00 | $3,020.42 | $4,933.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,056.00 / $3,020.42 / $3,249.82
| Professional | | $2,056.00 | $3,020.42 | $3,249.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.08 / $3,569.00 / $6,036.00
| Facility | | $1,181.08 | $3,569.00 | $6,036.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,647.05 / $4,610.12 / $5,978.18
| Professional | | $3,647.05 | $4,610.12 | $5,978.18 |