- 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
- $12,882.50 / $19,498.45 / $33,884.42
| Facility | | $12,882.50 | $19,498.45 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,481.54 / $12,022.64 / $12,589.25
| Professional | | $11,481.54 | $12,022.64 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $11,481.54 / $12,589.25
| Professional | | $457.09 | $11,481.54 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,244.36 / $25,703.96
| Facility | | $2,511.89 | $7,244.36 | $25,703.96 |