- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $4,917.20 / $8,042.03
| Facility | | $3,468.00 | $4,917.20 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,014.00 / $4,014.00 / $4,014.00
| Professional | | $4,014.00 | $4,014.00 | $4,014.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $17,843.63 / $17,843.63
| Professional | | $150.00 | $17,843.63 | $17,843.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,398.00 / $15,622.00 / $22,021.33
| Facility | | $10,398.00 | $15,622.00 | $22,021.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,352.00 / $15,202.00 / $21,188.59
| Facility | | $10,352.00 | $15,202.00 | $21,188.59 |