- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $3,630.78
| Facility | | $478.63 | $478.63 | $3,630.78 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $6,165.95 / $9,772.37
| Facility | | $3,388.44 | $6,165.95 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $660.69 / $660.69
| Professional | | $602.56 | $660.69 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,548.13 / $23,988.33
| Facility | | $2,041.74 | $3,548.13 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,162.28 / $3,162.28
| Facility | | $1,318.26 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,584.89 / $4,466.84
| Professional | | $1,318.26 | $1,584.89 | $4,466.84 |