- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.00 / $477.00 / $5,497.39
| Facility | | $477.00 | $477.00 | $5,497.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.00 / $477.00 / $2,748.70
| Professional | | $477.00 | $477.00 | $2,748.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,053.62 / $2,382.19 / $5,667.99
| Facility | | $2,053.62 | $2,382.19 | $5,667.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,843.48 / $2,843.48 / $2,843.48
| Facility | | $2,843.48 | $2,843.48 | $2,843.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,895.65 / $3,159.42
| Professional | | $1,326.96 | $1,895.65 | $3,159.42 |