- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,762.47 / $7,762.47
| Professional | | $5,623.41 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,715.35 / $12,882.50
| Professional | | $3,162.28 | $3,715.35 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $7,762.47 / $8,511.38
| Facility | | $4,168.69 | $7,762.47 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,122.02 / $4,677.35
| Facility | | $316.23 | $1,122.02 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,467.37 / $5,754.40
| Professional | | $2,344.23 | $3,467.37 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $7,413.10 / $7,413.10
| Facility | | $100.00 | $7,413.10 | $7,413.10 |