- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $8,511.38
| Facility | | $977.24 | $977.24 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $1,023.29 / $4,168.69
| Professional | | $95.50 | $1,023.29 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $2,818.38 / $11,220.18
| Facility | | $489.78 | $2,818.38 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,370.32 / $11,748.98
| Facility | | $2,691.53 | $5,370.32 | $11,748.98 |