- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $1,819.70 / $2,137.96
| Facility | | $446.68 | $1,819.70 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,778.28 / $2,089.30
| Professional | | $1,380.38 | $1,778.28 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,290.87 / $2,290.87
| Professional | | $1,174.90 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,677.35 / $8,128.31
| Facility | | $1,479.11 | $4,677.35 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $10,715.19
| Facility | | $10,715.19 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $16,982.44 / $16,982.44
| Professional | | $11,220.18 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,290.87 / $2,290.87
| Facility | | $812.83 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $2,290.87
| Professional | | $954.99 | $1,380.38 | $2,290.87 |