- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,394.75 / $7,822.39 / $23,017.60
| Facility | | $5,394.75 | $7,822.39 | $23,017.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,394.75 / $5,610.54 / $6,833.35
| Professional | | $5,394.75 | $5,610.54 | $6,833.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,740.36 / $9,494.76 / $14,170.21
| Professional | | $3,740.36 | $9,494.76 | $14,170.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,913.10 / $15,497.38 / $25,683.02
| Facility | | $4,913.10 | $15,497.38 | $25,683.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,275.89 / $4,949.54 / $12,360.45
| Professional | | $3,275.89 | $4,949.54 | $12,360.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,515.82 / $34,166.75 / $34,166.75
| Facility | | $12,515.82 | $34,166.75 | $34,166.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35,821.14 / $35,821.14 / $53,947.50
| Professional | | $35,821.14 | $35,821.14 | $53,947.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.06 / $4,315.80 / $7,193.00
| Professional | | $3,021.06 | $4,315.80 | $7,193.00 |