- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,597.19 / $8,279.18 / $8,544.31
| Facility | | $5,597.19 | $8,279.18 | $8,544.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,597.19 / $6,944.98 / $11,660.81
| Professional | | $5,597.19 | $6,944.98 | $11,660.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,251.13 / $12,863.69 / $56,551.22
| Facility | | $12,251.13 | $12,863.69 | $56,551.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,813.33 / $7,450.05 / $9,911.69
| Professional | | $6,813.33 | $7,450.05 | $9,911.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,077.06 / $9,077.06 / $9,077.06
| Facility | | $9,077.06 | $9,077.06 | $9,077.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,626.25 / $6,626.25 / $9,349.37
| Professional | | $6,626.25 | $6,626.25 | $9,349.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,696.21 / $9,873.43 / $63,807.96
| Facility | | $5,696.21 | $9,873.43 | $63,807.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,093.30 / $6,653.09 / $12,395.72
| Professional | | $5,093.30 | $6,653.09 | $12,395.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,709.17 / $6,158.40 / $9,418.33
| Professional | | $4,709.17 | $6,158.40 | $9,418.33 |