- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,374.87 / $2,374.87 / $25,512.96
| Facility | | $2,374.87 | $2,374.87 | $25,512.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,374.87 / $2,374.87 / $2,374.87
| Professional | | $2,374.87 | $2,374.87 | $2,374.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,413.06 / $3,498.26 / $6,139.22
| Facility | | $2,413.06 | $3,498.26 | $6,139.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.38 / $2,374.87 / $4,156.02
| Facility | | $2,137.38 | $2,374.87 | $4,156.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,374.87 / $2,374.87 / $2,374.87
| Professional | | $2,374.87 | $2,374.87 | $2,374.87 |