- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,989.94 / $7,108.31 / $20,699.40
| Facility | | $5,989.94 | $7,108.31 | $20,699.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.54 / $5,686.65 / $6,429.71
| Professional | | $2,666.54 | $5,686.65 | $6,429.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,942.74 / $10,008.50 / $14,936.93
| Professional | | $3,942.74 | $10,008.50 | $14,936.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,178.95 / $16,336.28 / $27,073.15
| Facility | | $5,178.95 | $16,336.28 | $27,073.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,582.20 / $7,582.20 / $36,546.19
| Professional | | $7,582.20 | $7,582.20 | $36,546.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,193.03 / $36,015.44 / $36,015.44
| Facility | | $13,193.03 | $36,015.44 | $36,015.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37,759.36 / $37,759.36 / $56,866.50
| Professional | | $37,759.36 | $37,759.36 | $56,866.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,184.52 / $4,549.32 / $7,582.20
| Professional | | $3,184.52 | $4,549.32 | $7,582.20 |