- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $1,905.46 / $2,238.72
| Facility | | $181.97 | $1,905.46 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,089.30
| Professional | | $1,905.46 | $1,905.46 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $6,025.60
| Facility | | $1,905.46 | $2,344.23 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $1,905.46 / $2,630.27
| Professional | | $114.82 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,905.46 / $4,466.84
| Facility | | $1,778.28 | $1,905.46 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,691.53
| Professional | | $1,905.46 | $1,905.46 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $4,570.88
| Facility | | $2,344.23 | $3,162.28 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $2,041.74 / $2,344.23
| Professional | | $125.89 | $2,041.74 | $2,344.23 |