- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $6,165.95 / $7,585.78
| Facility | | $2,137.96 | $6,165.95 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,454.71 / $6,760.83
| Professional | | $2,137.96 | $2,454.71 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $2,344.23 / $2,818.38
| Professional | | $537.03 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,818.38 / $7,762.47
| Professional | | $2,398.83 | $2,818.38 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,495.41 / $6,165.95
| Professional | | $2,511.89 | $5,495.41 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $8,128.31 / $26,302.68
| Facility | | $1,023.29 | $8,128.31 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $5,888.44
| Professional | | $1,995.26 | $2,691.53 | $5,888.44 |