- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $5,099.70
| Facility | | $2,116.32 | $2,116.32 | $5,099.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,285.63 / $4,067.00
| Professional | | $2,116.32 | $2,285.63 | $4,067.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,924.94 / $2,408.36 / $4,123.83
| Facility | | $1,924.94 | $2,408.36 | $4,123.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.59 / $2,113.23 / $2,113.23
| Professional | | $1,690.59 | $2,113.23 | $2,113.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,664.64 / $3,253.93 / $6,728.49
| Facility | | $2,664.64 | $3,253.93 | $6,728.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,139.10 / $2,478.61 / $2,689.76
| Professional | | $2,139.10 | $2,478.61 | $2,689.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,532.69 / $5,298.02 / $7,706.22
| Facility | | $2,532.69 | $5,298.02 | $7,706.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.92 / $2,117.92 / $2,880.38
| Professional | | $2,117.92 | $2,117.92 | $2,880.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $916.13 / $2,113.23 / $5,204.32
| Facility | | $916.13 | $2,113.23 | $5,204.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.23 / $2,113.23 / $3,149.64
| Professional | | $2,113.23 | $2,113.23 | $3,149.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $3,809.38
| Professional | | $2,116.32 | $2,116.32 | $3,809.38 |