- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $1,949.84 / $2,290.87
| Facility | | $181.97 | $1,949.84 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,187.76
| Professional | | $1,949.84 | $1,949.84 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,454.71 / $6,309.57
| Facility | | $1,949.84 | $2,454.71 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,949.84 / $2,691.53
| Professional | | $125.89 | $1,949.84 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,949.84 / $1,949.84
| Facility | | $1,862.09 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $1,949.84 / $1,949.84
| Professional | | $186.21 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,630.78 / $5,248.07
| Facility | | $2,290.87 | $3,630.78 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,819.70 / $2,238.72
| Professional | | $125.89 | $1,819.70 | $2,238.72 |