- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $6,760.83 / $12,589.25
| Facility | | $3,019.95 | $6,760.83 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $3,981.07
| Professional | | $3,801.89 | $3,890.45 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $6,606.93
| Facility | | $3,801.89 | $3,890.45 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $15,135.61 / $22,908.68
| Facility | | $6,760.83 | $15,135.61 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44,668.36 / $44,668.36 / $44,668.36
| Facility | | $44,668.36 | $44,668.36 | $44,668.36 |