- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Facility | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,019.95 / $3,467.37
| Professional | | $1,380.38 | $3,019.95 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,370.32 / $7,244.36
| Facility | | $3,467.37 | $5,370.32 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,467.37 / $3,890.45
| Facility | | $1,380.38 | $3,467.37 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $588.84 / $3,715.35
| Facility | | $295.12 | $588.84 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,019.95 / $6,918.31
| Professional | | $1,819.70 | $3,019.95 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $17,378.01 / $17,378.01
| Facility | | $5,754.40 | $17,378.01 | $17,378.01 |