- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $8,912.51 / $8,912.51
| Professional | | $6,456.54 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $5,128.61 / $18,620.87
| Professional | | $954.99 | $5,128.61 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $8,912.51 / $9,772.37
| Facility | | $4,786.30 | $8,912.51 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,318.26 / $5,370.32
| Facility | | $371.54 | $1,318.26 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,073.80 / $6,760.83
| Professional | | $2,754.23 | $4,073.80 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $8,511.38 / $8,511.38
| Facility | | $100.00 | $8,511.38 | $8,511.38 |