- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,481.54 / $11,481.54 / $11,481.54
| Professional | | $11,481.54 | $11,481.54 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,981.07 / $11,220.18
| Facility | | $1,995.26 | $3,981.07 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,265.80 / $9,772.37
| Facility | | $1,995.26 | $4,265.80 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $14,791.08 / $30,199.52
| Professional | | $6,606.93 | $14,791.08 | $30,199.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $4,265.80 / $11,220.18
| Facility | | $2,041.74 | $4,265.80 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $4,265.80 / $17,378.01
| Facility | | $1,862.09 | $4,265.80 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $21,379.62 / $28,183.83
| Professional | | $7,413.10 | $21,379.62 | $28,183.83 |