- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $13,803.84 / $14,125.38
| Professional | | $6,760.83 | $13,803.84 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $11,220.18 / $20,892.96
| Professional | | $1,288.25 | $11,220.18 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $7,244.36 / $8,912.51
| Professional | | $4,073.80 | $7,244.36 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,022.64 / $12,302.69 / $12,302.69
| Professional | | $12,022.64 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $11,220.18
| Professional | | $1,230.27 | $1,862.09 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,230.27 / $8,128.31
| Facility | | $616.60 | $1,230.27 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,128.61 / $10,000.00
| Professional | | $1,380.38 | $5,128.61 | $10,000.00 |