- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,191.44 / $11,521.20 / $11,521.20
| Professional | | $6,191.44 | $11,521.20 | $11,521.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,102.62 / $10,102.62 / $10,102.62
| Facility | | $10,102.62 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.52 / $10,102.62 / $23,835.94
| Professional | | $1,220.52 | $10,102.62 | $23,835.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,191.44 / $11,521.20 / $12,961.35
| Facility | | $6,191.44 | $11,521.20 | $12,961.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,560.40 / $9,560.40 / $9,560.40
| Professional | | $9,560.40 | $9,560.40 | $9,560.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,224.19 / $5,240.60 / $8,581.73
| Professional | | $3,224.19 | $5,240.60 | $8,581.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $11,041.73 / $11,041.73
| Facility | | $100.00 | $11,041.73 | $11,041.73 |