- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,309.57 / $6,606.93
| Professional | | $4,677.35 | $6,309.57 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $9,772.37
| Facility | | $9,772.37 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $9,772.37
| Professional | | $9,772.37 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $8,709.64 / $20,417.38
| Facility | | $6,760.83 | $8,709.64 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $8,709.64 / $20,417.38
| Professional | | $6,760.83 | $8,709.64 | $20,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $9,772.37 / $14,791.08
| Facility | | $6,025.60 | $9,772.37 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $8,511.38
| Professional | | $79.43 | $79.43 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $6,760.83
| Professional | | $2,818.38 | $2,818.38 | $6,760.83 |