- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $4,964.00 / $9,185.68
| Facility | | $4,146.00 | $4,964.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.07 / $1,728.51 / $4,147.20
| Professional | | $1,091.07 | $1,728.51 | $4,147.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,758.04 / $3,218.06 / $13,882.69
| Facility | | $1,758.04 | $3,218.06 | $13,882.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,820.64 / $2,545.83 / $3,464.98
| Facility | | $1,820.64 | $2,545.83 | $3,464.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,346.00 / $14,242.22
| Facility | | $8,220.00 | $9,346.00 | $14,242.22 |