- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,157.10 / $2,157.10 / $2,157.10
| Facility | | $2,157.10 | $2,157.10 | $2,157.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.00 / $1,980.61 / $2,157.10
| Professional | | $1,961.00 | $1,980.61 | $2,157.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,624.09 / $3,836.91 / $9,488.73
| Facility | | $1,624.09 | $3,836.91 | $9,488.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,649.47 / $2,030.11 / $4,796.14
| Professional | | $1,649.47 | $2,030.11 | $4,796.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,961.00 / $1,961.00 / $1,961.00
| Facility | | $1,961.00 | $1,961.00 | $1,961.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.00 / $1,961.00 / $1,961.00
| Professional | | $1,961.00 | $1,961.00 | $1,961.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,911.82 / $2,274.76 / $4,378.91
| Facility | | $1,911.82 | $2,274.76 | $4,378.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.00 / $1,961.00 / $4,255.37
| Professional | | $1,961.00 | $1,961.00 | $4,255.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.00 / $1,961.00 / $1,961.00
| Professional | | $1,961.00 | $1,961.00 | $1,961.00 |