- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $6,165.95 / $9,549.93
| Facility | | $1,412.54 | $6,165.95 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $15,848.93 / $15,848.93
| Professional | | $1,584.89 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $5,370.32 / $9,549.93
| Facility | | $1,122.02 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $6,025.60 / $15,848.93
| Professional | | $707.95 | $6,025.60 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $8,128.31 / $56,234.13
| Facility | | $3,311.31 | $8,128.31 | $56,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,218.10
| Professional | | $16,218.10 | $16,218.10 | $16,218.10 |