- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $3,162.28 / $6,760.83
| Facility | | $676.08 | $3,162.28 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $691.83 / $1,412.54
| Professional | | $371.54 | $691.83 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,288.25 / $8,128.31
| Facility | | $724.44 | $1,288.25 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,122.02 / $1,513.56
| Professional | | $891.25 | $1,122.02 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,309.57 / $8,912.51
| Facility | | $4,365.16 | $6,309.57 | $8,912.51 |