- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $7,413.10 / $7,413.10
| Professional | | $5,370.32 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $7,585.78 / $15,848.93
| Professional | | $912.01 | $7,585.78 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $7,413.10 / $8,128.31
| Facility | | $1,071.52 | $7,413.10 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $1,071.52 / $5,370.32
| Facility | | $331.13 | $1,071.52 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,548.13 / $5,888.44
| Professional | | $2,344.23 | $3,548.13 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $7,762.47 / $7,762.47
| Facility | | $100.00 | $7,762.47 | $7,762.47 |