- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $9,772.37
| Facility | | $1,819.70 | $2,454.71 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $245.47 / $2,454.71
| Professional | | $75.86 | $245.47 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $12,022.64 / $22,908.68
| Facility | | $10,964.78 | $12,022.64 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |