- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,531.66 / $13,531.66 / $13,531.66
| Professional | | $13,531.66 | $13,531.66 | $13,531.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,619.91 / $11,619.91 / $11,619.91
| Facility | | $11,619.91 | $11,619.91 | $11,619.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,531.66 / $13,531.66 / $23,003.82
| Facility | | $13,531.66 | $13,531.66 | $23,003.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.80 / $931.80 / $7,748.77
| Professional | | $931.80 | $931.80 | $7,748.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.80 / $931.80 / $931.80
| Professional | | $931.80 | $931.80 | $931.80 |