- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $3,981.07 / $6,760.83
| Facility | | $776.25 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $660.69 / $2,041.74
| Professional | | $380.19 | $660.69 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,202.26 / $8,317.64
| Facility | | $741.31 | $1,202.26 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,047.13 / $1,348.96
| Professional | | $870.96 | $1,047.13 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,606.93 / $8,912.51
| Facility | | $4,365.16 | $6,606.93 | $8,912.51 |