- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,265.80 / $9,772.37
| Facility | | $1,202.26 | $4,265.80 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $16,595.87 / $16,595.87
| Professional | | $1,513.56 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $18,620.87 / $22,387.21
| Facility | | $16,595.87 | $18,620.87 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,620.87 / $18,620.87 / $18,620.87
| Facility | | $18,620.87 | $18,620.87 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $199.53 / $346.74
| Professional | | $100.00 | $199.53 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $7,943.28 / $16,982.44
| Facility | | $2,570.40 | $7,943.28 | $16,982.44 |