- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.52 / $2,536.94 / $8,513.68
| Facility | | $205.52 | $2,536.94 | $8,513.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.04 / $528.17 / $987.14
| Professional | | $200.04 | $528.17 | $987.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.52 / $405.84 / $1,369.38
| Professional | | $249.52 | $405.84 | $1,369.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,319.39 / $2,319.39 / $2,319.39
| Facility | | $2,319.39 | $2,319.39 | $2,319.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.88 / $1,070.53 / $2,011.81
| Professional | | $872.88 | $1,070.53 | $2,011.81 |