- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,146.14 / $2,146.14 / $2,146.14
| Facility | | $2,146.14 | $2,146.14 | $2,146.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.14 / $2,452.73 / $2,452.73
| Professional | | $2,146.14 | $2,452.73 | $2,452.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,980.20 / $4,379.87 / $4,379.87
| Professional | | $2,980.20 | $4,379.87 | $4,379.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.06 / $2,853.06 / $2,853.06
| Facility | | $2,853.06 | $2,853.06 | $2,853.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,853.06 / $2,853.06
| Professional | | $2,082.73 | $2,853.06 | $2,853.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,470.57 / $3,004.18 / $24,371.76
| Facility | | $1,470.57 | $3,004.18 | $24,371.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.59 / $3,010.10 / $5,063.56
| Professional | | $1,518.59 | $3,010.10 | $5,063.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.59 / $2,325.67 / $3,431.32
| Professional | | $1,518.59 | $2,325.67 | $3,431.32 |