- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.24 / $7,756.32 / $7,756.32
| Professional | | $4,168.24 | $7,756.32 | $7,756.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $3,704.40
| Facility | | $3,704.40 | $3,704.40 | $3,704.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,148.74 / $3,704.40 / $12,836.25
| Professional | | $3,148.74 | $3,704.40 | $12,836.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.24 / $7,756.32 / $8,725.86
| Facility | | $4,168.24 | $7,756.32 | $8,725.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,446.90 / $6,446.90 / $6,446.90
| Professional | | $6,446.90 | $6,446.90 | $6,446.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,121.92 / $3,504.40 / $5,878.00
| Professional | | $2,121.92 | $3,504.40 | $5,878.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $7,433.65 / $7,433.65
| Facility | | $100.00 | $7,433.65 | $7,433.65 |