- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,979.56 / $3,128.53 / $3,128.53
| Facility | | $2,979.56 | $3,128.53 | $3,128.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $3,128.53
| Professional | | $2,979.56 | $2,979.56 | $3,128.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $3,993.80
| Professional | | $2,979.56 | $2,979.56 | $3,993.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $2,979.56
| Professional | | $2,979.56 | $2,979.56 | $2,979.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,810.90 / $2,810.90 / $2,979.55
| Facility | | $2,810.90 | $2,810.90 | $2,979.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.55 / $2,979.55 / $2,979.55
| Professional | | $2,979.55 | $2,979.55 | $2,979.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,532.62 / $2,569.84 / $2,979.55
| Professional | | $2,532.62 | $2,569.84 | $2,979.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,850.00 / $2,979.56 / $4,764.75
| Facility | | $2,850.00 | $2,979.56 | $4,764.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,850.00 / $2,850.00 / $2,850.00
| Professional | | $2,850.00 | $2,850.00 | $2,850.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,594.62 / $3,380.62 / $5,237.14
| Facility | | $2,594.62 | $3,380.62 | $5,237.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,594.62 / $3,380.62 / $5,237.14
| Professional | | $2,594.62 | $3,380.62 | $5,237.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,919.97 / $2,979.56 / $3,130.03
| Professional | | $2,919.97 | $2,979.56 | $3,130.03 |