- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,654.43 / $7,145.93 / $9,527.90
| Facility | | $4,654.43 | $7,145.93 | $9,527.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,161.60 / $4,654.43 / $5,311.53
| Professional | | $4,161.60 | $4,654.43 | $5,311.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,702.85 / $3,956.00 / $10,089.99
| Professional | | $1,702.85 | $3,956.00 | $10,089.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,542.09 / $10,574.59 / $13,051.84
| Facility | | $7,542.09 | $10,574.59 | $13,051.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,354.98 / $6,354.98 / $6,354.98
| Professional | | $6,354.98 | $6,354.98 | $6,354.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,654.43 / $6,570.96 / $26,010.05
| Facility | | $4,654.43 | $6,570.96 | $26,010.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $3,285.48 / $27,269.48
| Professional | | $2,299.84 | $3,285.48 | $27,269.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $3,285.48 / $6,193.13
| Professional | | $2,299.84 | $3,285.48 | $6,193.13 |