- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,128.61 / $11,481.54
| Professional | | $3,801.89 | $5,128.61 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Facility | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,456.54 / $6,918.31
| Professional | | $4,073.80 | $6,456.54 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $7,079.46 / $7,762.47
| Facility | | $6,760.83 | $7,079.46 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $7,079.46 / $7,762.47
| Professional | | $6,760.83 | $7,079.46 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,888.44 / $6,918.31
| Facility | | $3,715.35 | $5,888.44 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $4,073.80 / $8,317.64
| Professional | | $79.43 | $4,073.80 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,918.31 / $10,000.00
| Professional | | $5,495.41 | $6,918.31 | $10,000.00 |