- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,984.39 / $1,984.39 / $1,984.39
| Facility | | $1,984.39 | $1,984.39 | $1,984.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,984.39 / $4,010.61 / $6,893.03
| Professional | | $1,984.39 | $4,010.61 | $6,893.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.75 / $2,821.49 / $2,821.49
| Professional | | $626.75 | $2,821.49 | $2,821.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,395.09 / $4,346.88 / $6,003.73
| Professional | | $3,395.09 | $4,346.88 | $6,003.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $862.17 / $2,986.18 / $5,064.60
| Professional | | $862.17 | $2,986.18 | $5,064.60 |