- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $3,981.07 / $6,760.83
| Facility | | $489.78 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $588.84 / $1,584.89
| Professional | | $331.13 | $588.84 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $2,951.21 / $9,332.54
| Facility | | $588.84 | $2,951.21 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $794.33 / $1,202.26
| Professional | | $724.44 | $794.33 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,456.54 / $9,332.54
| Facility | | $4,365.16 | $6,456.54 | $9,332.54 |