- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,309.57 / $10,964.78
| Facility | | $3,162.28 | $6,309.57 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,623.41 / $9,332.54
| Professional | | $5,011.87 | $5,623.41 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Professional | | $8,709.64 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $8,128.31 / $12,302.69
| Professional | | $5,623.41 | $8,128.31 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $4,897.79 / $10,232.93
| Facility | | $54.95 | $4,897.79 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,760.83 / $40,738.03
| Professional | | $5,754.40 | $6,760.83 | $40,738.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,445.44 / $5,623.41
| Facility | | $851.14 | $1,445.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,309.57 / $9,549.93
| Professional | | $5,754.40 | $6,309.57 | $9,549.93 |