- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,788.75 / $2,788.75 / $6,907.00
| Facility | | $2,788.75 | $2,788.75 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.10 / $1,085.11 / $1,193.63
| Professional | | $1,085.10 | $1,085.11 | $1,193.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,151.00 / $2,151.00 / $2,151.00
| Facility | | $2,151.00 | $2,151.00 | $2,151.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,640.16 / $7,640.16 / $10,739.69
| Facility | | $7,640.16 | $7,640.16 | $10,739.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,663.00 / $2,530.00 / $2,530.00
| Facility | | $1,663.00 | $2,530.00 | $2,530.00 |