- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $7,762.47 / $16,595.87
| Facility | | $4,677.35 | $7,762.47 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $9,120.11
| Professional | | $7,244.36 | $7,244.36 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,786.30 / $6,918.31
| Facility | | $4,073.80 | $4,786.30 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $20,417.38 / $25,703.96
| Facility | | $3,019.95 | $20,417.38 | $25,703.96 |