- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,466.84 / $4,466.84
| Facility | | $1,778.28 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $4,786.30 / $6,309.57
| Professional | | $616.60 | $4,786.30 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $10,964.78 / $13,489.63
| Professional | | $707.95 | $10,964.78 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $1,023.29 / $1,479.11
| Professional | | $489.78 | $1,023.29 | $1,479.11 |