- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,471.29 / $12,589.25 / $24,547.09
| Professional | | $10,471.29 | $12,589.25 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,218.10
| Facility | | $16,218.10 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Professional | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.89 / $16,982.44 / $19,498.45
| Facility | | $20.89 | $16,982.44 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,882.50 / $15,135.61 / $21,379.62
| Professional | | $12,882.50 | $15,135.61 | $21,379.62 |