- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $1,698.24
| Facility | | $501.19 | $501.19 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $489.78 / $549.54
| Professional | | $354.81 | $489.78 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $10,471.29
| Facility | | $2,884.03 | $2,884.03 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $645.65 / $954.99
| Professional | | $426.58 | $645.65 | $954.99 |