- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,008.05 / $2,047.43 / $2,047.43
| Facility | | $2,008.05 | $2,047.43 | $2,047.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.71 / $2,047.43 / $3,517.44
| Professional | | $1,752.71 | $2,047.43 | $3,517.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,815.73 / $4,253.31 / $4,253.31
| Professional | | $2,815.73 | $4,253.31 | $4,253.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $3,001.57
| Facility | | $3,001.57 | $3,001.57 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $2,191.15 / $3,001.57
| Professional | | $2,191.15 | $2,191.15 | $3,001.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,384.22 / $21,089.02 / $22,464.46
| Facility | | $7,384.22 | $21,089.02 | $22,464.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,129.32 / $26,129.32 / $30,206.70
| Professional | | $26,129.32 | $26,129.32 | $30,206.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.80 / $2,357.69 / $3,043.56
| Professional | | $1,571.80 | $2,357.69 | $3,043.56 |