- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,995.26 / $2,344.23
| Facility | | $489.78 | $1,995.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,862.09 / $2,344.23
| Professional | | $1,621.81 | $1,862.09 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,511.89 / $2,511.89
| Professional | | $1,621.81 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $5,128.61 / $7,079.46
| Facility | | $1,621.81 | $5,128.61 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $3,801.89
| Professional | | $2,884.03 | $3,019.95 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Facility | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,698.24 / $2,511.89
| Facility | | $891.25 | $1,698.24 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $2,511.89
| Professional | | $1,047.13 | $1,479.11 | $2,511.89 |