- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $8,511.38
| Facility | | $575.44 | $575.44 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $575.44 / $1,445.44
| Professional | | $524.81 | $575.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,288.25 / $1,548.82
| Professional | | $1,047.13 | $1,288.25 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,122.02 / $1,819.70
| Professional | | $660.69 | $1,122.02 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $1,737.80
| Facility | | $575.44 | $724.44 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,023.29 / $5,011.87
| Professional | | $575.44 | $1,023.29 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,677.35 / $5,128.61
| Facility | | $3,090.30 | $4,677.35 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,023.29 / $1,380.38
| Professional | | $575.44 | $1,023.29 | $1,380.38 |