- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,728.43 / $8,794.83 / $11,726.40
| Facility | | $5,728.43 | $8,794.83 | $11,726.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,121.89 / $5,728.43 / $6,537.15
| Professional | | $5,121.89 | $5,728.43 | $6,537.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.88 / $4,868.83 / $12,418.25
| Professional | | $426.88 | $4,868.83 | $12,418.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,282.41 / $13,014.64 / $16,063.51
| Facility | | $9,282.41 | $13,014.64 | $16,063.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,821.60 / $7,821.60 / $7,821.60
| Professional | | $7,821.60 | $7,821.60 | $7,821.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,728.43 / $8,087.20 / $32,011.82
| Facility | | $5,728.43 | $8,087.20 | $32,011.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,830.52 / $4,043.60 / $33,561.86
| Professional | | $2,830.52 | $4,043.60 | $33,561.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,830.52 / $4,043.60 / $7,622.18
| Professional | | $2,830.52 | $4,043.60 | $7,622.18 |