- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $936.03 / $1,996.78 / $2,202.64
| Facility | | $936.03 | $1,996.78 | $2,202.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.78 / $1,996.78 / $2,150.81
| Professional | | $1,996.78 | $1,996.78 | $2,150.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.36 / $1,782.36 / $2,267.42
| Professional | | $1,782.36 | $1,782.36 | $2,267.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,202.64 / $2,202.64 / $2,202.64
| Facility | | $2,202.64 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,202.64 / $2,202.64 / $2,591.34
| Professional | | $2,202.64 | $2,202.64 | $2,591.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,996.78 / $2,116.59 / $2,850.47
| Facility | | $1,996.78 | $2,116.59 | $2,850.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.91 / $550.91 / $550.91
| Professional | | $550.91 | $550.91 | $550.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.44 / $2,159.44 / $3,347.15
| Professional | | $2,159.44 | $2,159.44 | $3,347.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,461.77 / $2,461.77 / $11,383.05
| Facility | | $2,461.77 | $2,461.77 | $11,383.05 |