- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,054.83 / $2,054.83 / $2,054.83
| Facility | | $2,054.83 | $2,054.83 | $2,054.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $2,054.83 / $2,054.83
| Professional | | $1,902.62 | $2,054.83 | $2,054.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.93 / $1,794.93 / $1,902.62
| Facility | | $1,794.93 | $1,794.93 | $1,902.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Professional | | $1,902.62 | $1,902.62 | $1,902.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,140.42 / $2,311.66 / $3,130.17
| Facility | | $2,140.42 | $2,311.66 | $3,130.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.43 / $2,038.50 / $10,260.00
| Professional | | $1,997.43 | $2,038.50 | $10,260.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.42 / $1,902.62 / $2,108.10
| Professional | | $1,828.42 | $1,902.62 | $2,108.10 |