- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $1,949.84 / $2,344.23
| Facility | | $181.97 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,290.87
| Professional | | $1,949.84 | $1,949.84 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,398.83 / $5,754.40
| Facility | | $1,949.84 | $2,398.83 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $1,949.84 / $2,951.21
| Professional | | $190.55 | $1,949.84 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,949.84 / $3,630.78
| Facility | | $1,862.09 | $1,949.84 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,398.83
| Professional | | $1,949.84 | $1,949.84 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $3,890.45
| Facility | | $1,995.26 | $2,691.53 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,905.46 / $1,995.26
| Professional | | $125.89 | $1,905.46 | $1,995.26 |