- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,715.35 / $8,128.31
| Facility | | $1,995.26 | $3,715.35 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,570.40 / $3,090.30
| Professional | | $2,511.89 | $2,570.40 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,162.28 / $6,025.60
| Facility | | $2,137.96 | $3,162.28 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,570.40 / $3,311.31
| Professional | | $2,137.96 | $2,570.40 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $7,413.10
| Facility | | $2,630.27 | $2,630.27 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $3,388.44
| Professional | | $2,630.27 | $2,630.27 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $2,454.71
| Facility | | $1,380.38 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,090.30
| Professional | | $2,570.40 | $2,570.40 | $3,090.30 |