- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $4,786.30
| Facility | | $457.09 | $457.09 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $2,137.96 / $2,691.53
| Professional | | $457.09 | $2,137.96 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,715.35
| Professional | | $2,454.71 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,548.13 / $5,128.61
| Facility | | $1,778.28 | $3,548.13 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,754.23
| Facility | | $2,454.71 | $2,454.71 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $2,754.23
| Professional | | $1,148.15 | $1,659.59 | $2,754.23 |