- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,099.00 / $10,026.04 / $12,722.24
| Professional | | $9,099.00 | $10,026.04 | $12,722.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,511.57 / $11,155.72 / $11,155.72
| Facility | | $6,511.57 | $11,155.72 | $11,155.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.76 / $11,155.72 / $11,155.72
| Professional | | $1,347.76 | $11,155.72 | $11,155.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,026.04 / $10,527.35 / $12,722.24
| Facility | | $10,026.04 | $10,527.35 | $12,722.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,556.80 / $10,556.80 / $10,556.80
| Professional | | $10,556.80 | $10,556.80 | $10,556.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $439.66 / $3,165.61 / $5,862.25
| Professional | | $439.66 | $3,165.61 | $5,862.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,480.39 / $5,453.92 / $6,921.49
| Professional | | $3,480.39 | $5,453.92 | $6,921.49 |