- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,338.00 / $4,338.00 / $4,937.00
| Facility | | $4,338.00 | $4,338.00 | $4,937.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,154.57 / $15,154.57 / $15,154.57
| Professional | | $15,154.57 | $15,154.57 | $15,154.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,671.04 / $25,611.22 / $41,523.51
| Facility | | $21,671.04 | $25,611.22 | $41,523.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,378.74 / $17,809.79 / $24,526.62
| Facility | | $17,378.74 | $17,809.79 | $24,526.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |