- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,576.66 / $7,491.99 / $22,110.82
| Facility | | $3,576.66 | $7,491.99 | $22,110.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.17 / $4,722.00 / $9,251.04
| Professional | | $3,859.17 | $4,722.00 | $9,251.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.50 / $1,326.50 / $1,326.50
| Professional | | $1,326.50 | $1,326.50 | $1,326.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,050.00 / $3,859.17 / $4,438.05
| Facility | | $1,050.00 | $3,859.17 | $4,438.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |