- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,263.12 / $5,847.60 / $5,847.60
| Professional | | $4,263.12 | $5,847.60 | $5,847.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Facility | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.96 / $5,470.13 / $10,804.69
| Professional | | $651.96 | $5,470.13 | $10,804.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,263.12 / $5,847.60 / $7,017.12
| Facility | | $4,263.12 | $5,847.60 | $7,017.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,582.80 / $6,582.80 / $6,582.80
| Professional | | $6,582.80 | $6,582.80 | $6,582.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.17 / $3,224.53 / $5,956.99
| Professional | | $2,170.17 | $3,224.53 | $5,956.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $7,602.76 / $7,602.76
| Facility | | $100.00 | $7,602.76 | $7,602.76 |