- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,803.84 / $13,803.84 / $13,803.84
| Professional | | $13,803.84 | $13,803.84 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $10,715.19
| Facility | | $10,715.19 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $10,715.19 / $11,481.54
| Professional | | $1,230.27 | $10,715.19 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $10,964.78 / $13,803.84
| Facility | | $9,549.93 | $10,964.78 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $10,715.19
| Professional | | $79.43 | $79.43 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,148.15 / $7,762.47
| Facility | | $588.84 | $1,148.15 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,897.79 / $5,623.41
| Professional | | $4,466.84 | $4,897.79 | $5,623.41 |