- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $5,623.41
| Facility | | $478.63 | $478.63 | $5,623.41 |
- 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
- $4,570.88 / $6,309.57 / $7,079.46
| Professional | | $4,570.88 | $6,309.57 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $4,570.88
| Professional | | $3,630.78 | $3,630.78 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $1,778.28 / $4,786.30
| Facility | | $478.63 | $1,778.28 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,715.35 / $6,309.57
| Professional | | $1,318.26 | $3,715.35 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,235.94 / $5,370.32
| Professional | | $1,318.26 | $3,235.94 | $5,370.32 |