- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $5,495.41
| Facility | | $478.63 | $478.63 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $2,951.21
| Professional | | $478.63 | $478.63 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $4,265.80
| Professional | | $2,818.38 | $2,818.38 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $4,073.80 / $5,888.44
| Facility | | $2,041.74 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,162.28
| Facility | | $2,818.38 | $2,818.38 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $3,162.28
| Professional | | $1,318.26 | $1,905.46 | $3,162.28 |