- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,019.95 / $3,630.78
| Facility | | $2,630.27 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $3,981.07
| Professional | | $2,137.96 | $3,019.95 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $8,128.31
| Facility | | $371.54 | $371.54 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $4,466.84
| Professional | | $2,089.30 | $2,754.23 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,090.30
| Facility | | $2,691.53 | $2,691.53 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,691.53 / $6,309.57
| Professional | | $2,290.87 | $2,691.53 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $467.74 / $3,019.95
| Facility | | $213.80 | $467.74 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $3,467.37
| Professional | | $1,348.96 | $1,905.46 | $3,467.37 |