- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,947.43 / $9,206.32 / $9,206.32
| Professional | | $4,947.43 | $9,206.32 | $9,206.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,072.81 / $8,072.81 / $8,072.81
| Facility | | $8,072.81 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.29 / $8,072.81 / $19,045.31
| Professional | | $975.29 | $8,072.81 | $19,045.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,947.43 / $9,206.32 / $10,357.11
| Facility | | $4,947.43 | $9,206.32 | $10,357.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,639.40 / $7,639.40 / $7,639.40
| Professional | | $7,639.40 | $7,639.40 | $7,639.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,518.52 / $4,159.43 / $6,980.00
| Professional | | $2,518.52 | $4,159.43 | $6,980.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $8,823.10 / $8,823.10
| Facility | | $100.00 | $8,823.10 | $8,823.10 |