- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $4,802.52 / $24,903.40
| Professional | | $2,711.10 | $4,802.52 | $24,903.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,482.43 / $6,482.43 / $6,482.43
| Facility | | $6,482.43 | $6,482.43 | $6,482.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.74 / $4,386.20 / $8,702.29
| Professional | | $1,844.74 | $4,386.20 | $8,702.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,482.43 / $6,482.43 / $6,482.43
| Facility | | $6,482.43 | $6,482.43 | $6,482.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.74 / $4,386.20 / $8,702.29
| Professional | | $1,844.74 | $4,386.20 | $8,702.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,691.73 / $3,873.00 / $17,428.50
| Professional | | $1,691.73 | $3,873.00 | $17,428.50 |