- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,365.16 / $6,456.54
| Facility | | $3,548.13 | $4,365.16 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,025.60 / $8,511.38
| Professional | | $3,981.07 | $6,025.60 | $8,511.38 |
- 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
- $1,047.13 / $10,715.19 / $14,454.40
| Facility | | $1,047.13 | $10,715.19 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,071.52 / $52,480.75
| Professional | | $549.54 | $1,071.52 | $52,480.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,479.11
| Professional | | $1,174.90 | $1,174.90 | $1,479.11 |
- 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
- $588.84 / $1,479.11 / $15,488.17
| Professional | | $588.84 | $1,479.11 | $15,488.17 |