- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,466.84 / $4,897.79
| Facility | | $2,454.71 | $4,466.84 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,949.84 / $4,466.84
| Professional | | $1,819.70 | $1,949.84 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Professional | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $21.38 / $42.66
| Professional | | $16.98 | $21.38 | $42.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,951.21
| Facility | | $2,187.76 | $2,187.76 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $5,370.32
| Professional | | $1,023.29 | $1,445.44 | $5,370.32 |