- 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
- Professional
- Modifier
- Low / Median / High Price
- $9,876.92 / $9,876.92 / $9,876.92
| Professional | | $9,876.92 | $9,876.92 | $9,876.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,531.66 / $13,531.66 / $16,237.99
| Facility | | $13,531.66 | $13,531.66 | $16,237.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,748.77 / $7,748.77 / $7,748.77
| Professional | | $7,748.77 | $7,748.77 | $7,748.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $5,056.38
| Professional | | $30.00 | $30.00 | $5,056.38 |