- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,188.92 / $16,188.92 / $16,188.92
| Professional | | $16,188.92 | $16,188.92 | $16,188.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,777.03 / $10,777.03 / $10,777.03
| Professional | | $10,777.03 | $10,777.03 | $10,777.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,328.40 / $9,071.33 / $14,275.68
| Facility | | $6,328.40 | $9,071.33 | $14,275.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,468.91 / $1,468.91 / $1,546.22
| Professional | | $1,468.91 | $1,468.91 | $1,546.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,283.40 / $19,132.36 / $31,138.50
| Professional | | $12,283.40 | $19,132.36 | $31,138.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,328.40 / $9,071.33 / $14,275.68
| Facility | | $6,328.40 | $9,071.33 | $14,275.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.72 / $10,777.03 / $10,777.03
| Professional | | $1,471.72 | $10,777.03 | $10,777.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,275.26 / $13,944.24 / $24,361.19
| Professional | | $7,275.26 | $13,944.24 | $24,361.19 |