- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,626.48 / $7,537.36 / $7,537.36
| Professional | | $5,626.48 | $7,537.36 | $7,537.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,447.14 / $7,447.14 / $7,447.14
| Facility | | $7,447.14 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.86 / $7,447.14 / $7,447.14
| Professional | | $856.86 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.06 / $1,818.57 / $11,274.00
| Professional | | $707.06 | $1,818.57 | $11,274.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,563.92 / $6,157.28 / $9,342.08
| Facility | | $4,563.92 | $6,157.28 | $9,342.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.86 / $7,447.14 / $7,447.14
| Professional | | $856.86 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,168.92 / $3,427.44 / $5,163.00
| Professional | | $3,168.92 | $3,427.44 | $5,163.00 |