- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,816.00 / $5,816.00 / $6,907.00
| Facility | | $5,816.00 | $5,816.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.52 / $1,683.03 / $1,701.69
| Professional | | $1,525.52 | $1,683.03 | $1,701.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.75 / $1,715.04 / $3,070.07
| Professional | | $1,485.75 | $1,715.04 | $3,070.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,357.53 / $18,357.53 / $18,357.53
| Facility | | $18,357.53 | $18,357.53 | $18,357.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.42 / $1,695.40 / $3,975.07
| Professional | | $1,425.42 | $1,695.40 | $3,975.07 |