- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $5,248.07 / $7,943.28
| Facility | | $851.14 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $891.25 / $2,398.83
| Professional | | $512.86 | $891.25 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,162.28 / $9,549.93
| Facility | | $891.25 | $3,162.28 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $1,621.81
| Professional | | $1,071.52 | $1,202.26 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,762.47 / $10,964.78
| Facility | | $4,786.30 | $7,762.47 | $10,964.78 |