- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,217.75 / $16,217.75 / $16,217.75
| Professional | | $16,217.75 | $16,217.75 | $16,217.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,820.61 / $9,676.92 / $24,659.07
| Facility | | $5,820.61 | $9,676.92 | $24,659.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,820.61 / $16,608.54 / $16,608.54
| Professional | | $5,820.61 | $16,608.54 | $16,608.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,820.61 / $9,676.92 / $24,659.07
| Facility | | $5,820.61 | $9,676.92 | $24,659.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,880.04 / $5,968.94 / $22,274.99
| Professional | | $3,880.04 | $5,968.94 | $22,274.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,282.88 / $16,282.88 / $16,282.88
| Professional | | $16,282.88 | $16,282.88 | $16,282.88 |