- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,611.59 / $9,611.59 / $12,196.32
| Professional | | $9,611.59 | $9,611.59 | $12,196.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,922.50 / $10,694.63 / $10,694.63
| Facility | | $6,922.50 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.04 / $10,694.63 / $10,694.63
| Professional | | $1,292.04 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,611.59 / $10,092.17 / $12,196.32
| Facility | | $9,611.59 | $10,092.17 | $12,196.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,120.50 / $10,120.50 / $10,120.50
| Professional | | $10,120.50 | $10,120.50 | $10,120.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,413.13 / $4,922.04 / $6,542.18
| Professional | | $3,413.13 | $4,922.04 | $6,542.18 |