- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.41 / $2,000.41 / $2,000.41
| Facility | | $2,000.41 | $2,000.41 | $2,000.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,000.41 / $2,000.41 / $3,328.21
| Professional | | $2,000.41 | $2,000.41 | $3,328.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,590.00 / $3,265.31 / $4,739.95
| Professional | | $2,590.00 | $3,265.31 | $4,739.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,991.50 / $3,813.78 / $4,210.72
| Facility | | $1,991.50 | $3,813.78 | $4,210.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.06 / $2,784.06 / $3,813.78
| Professional | | $2,784.06 | $2,784.06 | $3,813.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,989.86 / $3,204.00 / $7,022.71
| Facility | | $1,989.86 | $3,204.00 | $7,022.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,514.00 / $2,514.00 / $2,702.00
| Professional | | $2,514.00 | $2,514.00 | $2,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.64 / $3,021.64 / $3,021.64
| Professional | | $3,021.64 | $3,021.64 | $3,021.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,502.11 / $2,230.86 / $3,361.22
| Professional | | $1,502.11 | $2,230.86 | $3,361.22 |