- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,026.04 / $13,802.66 / $13,802.66
| Professional | | $10,026.04 | $13,802.66 | $13,802.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $657.78 / $657.78 / $822.22
| Facility | | $657.78 | $657.78 | $822.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,826.67 / $17,102.22 / $28,432.45
| Professional | | $12,826.67 | $17,102.22 | $28,432.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,155.72 / $11,155.72 / $11,155.72
| Facility | | $11,155.72 | $11,155.72 | $11,155.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.58 / $11,155.72 / $26,320.31
| Professional | | $1,283.58 | $11,155.72 | $26,320.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,836.80 / $10,872.65 / $15,182.93
| Facility | | $6,836.80 | $10,872.65 | $15,182.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,380.35 / $5,134.32 / $9,734.10
| Professional | | $4,380.35 | $5,134.32 | $9,734.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,380.35 / $5,134.32 / $9,734.10
| Professional | | $4,380.35 | $5,134.32 | $9,734.10 |