- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $2,089.30 / $2,398.83
| Facility | | $181.97 | $2,089.30 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,290.87
| Professional | | $2,089.30 | $2,089.30 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,570.40 / $6,025.60
| Facility | | $2,089.30 | $2,570.40 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $2,089.30 / $3,235.94
| Professional | | $125.89 | $2,089.30 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $2,089.30 / $2,089.30
| Facility | | $467.74 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $2,089.30 / $2,089.30
| Professional | | $223.87 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,570.88 / $6,760.83
| Facility | | $1,230.27 | $4,570.88 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $2,398.83 / $2,754.23
| Professional | | $125.89 | $2,398.83 | $2,754.23 |