- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $3,109.00 / $6,232.23
| Facility | | $1,277.00 | $3,109.00 | $6,232.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,391.68 / $4,629.42 / $4,629.42
| Professional | | $3,391.68 | $4,629.42 | $4,629.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,417.80 / $4,523.55 / $4,523.55
| Professional | | $3,417.80 | $4,523.55 | $4,523.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,056.00 / $2,558.00
| Facility | | $375.00 | $1,056.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,807.86 / $3,718.67 / $7,152.58
| Professional | | $2,807.86 | $3,718.67 | $7,152.58 |