- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,877.31 / $5,877.31 / $7,457.84
| Professional | | $5,877.31 | $5,877.31 | $7,457.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,760.00 / $4,700.00 / $5,925.46
| Professional | | $3,760.00 | $4,700.00 | $5,925.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,745.72 / $6,539.60 / $6,539.60
| Facility | | $4,745.72 | $6,539.60 | $6,539.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.06 / $6,539.60 / $6,539.60
| Professional | | $790.06 | $6,539.60 | $6,539.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,877.31 / $6,171.18 / $7,457.84
| Facility | | $5,877.31 | $6,171.18 | $7,457.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,028.50 / $6,028.50 / $6,028.50
| Professional | | $6,028.50 | $6,028.50 | $6,028.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.73 / $1,855.66 / $3,436.41
| Professional | | $257.73 | $1,855.66 | $3,436.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,040.17 / $3,197.08 / $4,125.59
| Professional | | $2,040.17 | $3,197.08 | $4,125.59 |