- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.30 / $861.69 / $4,007.20
| Facility | | $371.30 | $861.69 | $4,007.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.30 / $525.41 / $595.48
| Professional | | $371.30 | $525.41 | $595.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.59 / $917.73 / $1,276.42
| Professional | | $735.59 | $917.73 | $1,276.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,702.00 / $8,702.00 / $8,702.00
| Facility | | $8,702.00 | $8,702.00 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.24 / $420.34 / $714.57
| Professional | | $271.24 | $420.34 | $714.57 |