- 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
- $7,943.28 / $19,054.61 / $32,359.37
| Facility | | $7,943.28 | $19,054.61 | $32,359.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47,863.01 / $47,863.01 / $47,863.01
| Facility | | $47,863.01 | $47,863.01 | $47,863.01 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,073.80 / $9,120.11
| Facility | | $1,380.38 | $4,073.80 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $11.48 / $11.48
| Professional | | $11.48 | $11.48 | $11.48 |