- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.37 / $844.37 / $11,005.20
| Professional | | $844.37 | $844.37 | $11,005.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.61 / $6,449.19 / $8,598.93
| Professional | | $762.61 | $6,449.19 | $8,598.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,401.44 / $14,401.44 / $14,401.44
| Facility | | $14,401.44 | $14,401.44 | $14,401.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.00 / $1,311.00 / $14,401.44
| Professional | | $1,311.00 | $1,311.00 | $14,401.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,114.85 / $14,354.43 / $27,327.57
| Professional | | $10,114.85 | $14,354.43 | $27,327.57 |