- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,079.46 / $8,317.64
| Professional | | $5,754.40 | $7,079.46 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $7,585.78 / $7,762.47
| Professional | | $6,760.83 | $7,585.78 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $8,317.64 / $8,317.64
| Facility | | $5,888.44 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $13,182.57
| Professional | | $7,079.46 | $7,079.46 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $10,000.00
| Professional | | $8,128.31 | $8,128.31 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,079.46 / $8,912.51
| Professional | | $5,754.40 | $7,079.46 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,912.51 / $8,912.51 / $12,302.69
| Professional | | $8,912.51 | $8,912.51 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,096.48 / $7,244.36
| Facility | | $562.34 | $1,096.48 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,677.35 / $8,511.38
| Professional | | $3,388.44 | $4,677.35 | $8,511.38 |