- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,365.16 / $5,248.07
| Facility | | $3,548.13 | $4,365.16 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,248.07 / $5,495.41
| Professional | | $3,311.31 | $5,248.07 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $13,489.63 / $16,595.87
| Professional | | $13,489.63 | $13,489.63 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,943.28 / $9,332.54
| Facility | | $5,754.40 | $7,943.28 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,187.76 / $42,657.95
| Professional | | $1,023.29 | $2,187.76 | $42,657.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,570.40
| Professional | | $2,137.96 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,019.95 / $8,709.64
| Professional | | $1,023.29 | $3,019.95 | $8,709.64 |