- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,848.75 / $3,418.50 / $3,418.50
| Facility | | $2,848.75 | $3,418.50 | $3,418.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,709.25 / $1,937.15 / $1,937.15
| Professional | | $1,709.25 | $1,937.15 | $1,937.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,076.65 / $12,819.38 / $61,533.00
| Facility | | $3,076.65 | $12,819.38 | $61,533.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.80 / $3,076.65 / $119,998.80
| Professional | | $2,734.80 | $3,076.65 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,851.69 / $2,734.80 / $6,836.43
| Facility | | $1,851.69 | $2,734.80 | $6,836.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,984.78 / $10,984.78 / $10,984.78
| Professional | | $10,984.78 | $10,984.78 | $10,984.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.18 / $1,139.50 / $3,646.40
| Professional | | $957.18 | $1,139.50 | $3,646.40 |