- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,975.33 / $5,954.30 / $14,283.10
| Facility | | $3,975.33 | $5,954.30 | $14,283.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,975.33 / $4,673.04 / $6,233.47
| Professional | | $3,975.33 | $4,673.04 | $6,233.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,448.66 / $10,709.86 / $13,210.56
| Professional | | $6,448.66 | $10,709.86 | $13,210.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,551.49 / $7,551.49 / $7,551.49
| Facility | | $7,551.49 | $7,551.49 | $7,551.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,418.77 / $6,418.77 / $7,551.49
| Professional | | $6,418.77 | $6,418.77 | $7,551.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,329.43 / $11,068.82 / $45,439.44
| Facility | | $5,329.43 | $11,068.82 | $45,439.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,764.02 / $7,401.57 / $15,521.56
| Professional | | $4,764.02 | $7,401.57 | $15,521.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,632.46 / $5,829.49 / $14,173.49
| Professional | | $4,632.46 | $5,829.49 | $14,173.49 |