- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,220.18 / $19,054.61
| Professional | | $8,511.38 | $11,220.18 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $11,220.18 / $11,220.18
| Professional | | $1,288.25 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $2,754.23 / $20,892.96
| Professional | | $467.74 | $2,754.23 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,549.93 / $14,125.38
| Facility | | $6,760.83 | $9,549.93 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $9,549.93 / $11,220.18
| Professional | | $1,288.25 | $9,549.93 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,230.27 / $8,128.31
| Facility | | $707.95 | $1,230.27 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,128.61 / $8,128.31
| Professional | | $4,677.35 | $5,128.61 | $8,128.31 |