- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,280.28 / $2,280.28 / $2,280.28
| Facility | | $2,280.28 | $2,280.28 | $2,280.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,280.28 / $2,280.28 / $3,793.86
| Professional | | $2,280.28 | $2,280.28 | $3,793.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,950.00 / $3,719.17 / $5,403.12
| Professional | | $2,950.00 | $3,719.17 | $5,403.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,270.19 / $3,578.08 / $3,950.48
| Facility | | $2,270.19 | $3,578.08 | $3,950.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.00 / $2,612.00 / $3,501.18
| Professional | | $2,612.00 | $2,612.00 | $3,501.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,268.26 / $3,652.00 / $8,005.26
| Facility | | $2,268.26 | $3,652.00 | $8,005.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,866.00 / $2,866.00 / $3,080.00
| Professional | | $2,866.00 | $2,866.00 | $3,080.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,444.40 / $3,444.40 / $3,444.40
| Professional | | $3,444.40 | $3,444.40 | $3,444.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.67 / $2,520.29 / $3,632.67
| Professional | | $1,940.67 | $2,520.29 | $3,632.67 |