- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,134.44 / $2,134.44 / $3,874.50
| Facility | | $2,134.44 | $2,134.44 | $3,874.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,160.84 / $5,160.84 / $5,160.84
| Professional | | $5,160.84 | $5,160.84 | $5,160.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,517.61 / $2,196.16 / $3,798.60
| Facility | | $1,517.61 | $2,196.16 | $3,798.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.91 / $3,467.91 / $3,467.91
| Professional | | $3,467.91 | $3,467.91 | $3,467.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $5,160.84 / $10,321.68
| Facility | | $100.00 | $5,160.84 | $10,321.68 |