- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,918.31 / $8,912.51
| Facility | | $4,365.16 | $6,918.31 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $8,317.64 / $9,772.37
| Professional | | $5,623.41 | $8,317.64 | $9,772.37 |
- 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
- $3,801.89 / $14,125.38 / $16,595.87
| Facility | | $3,801.89 | $14,125.38 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,548.82 / $72,443.60
| Professional | | $691.83 | $1,548.82 | $72,443.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,862.09
| Professional | | $1,479.11 | $1,479.11 | $1,862.09 |
- 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
- $776.25 / $2,238.72 / $17,378.01
| Professional | | $776.25 | $2,238.72 | $17,378.01 |