- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,302.69 / $16,595.87 / $24,547.09
| Professional | | $12,302.69 | $16,595.87 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $45,708.82
| Facility | | $16,595.87 | $16,595.87 | $45,708.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,022.64 / $12,022.64 / $32,359.37
| Professional | | $12,022.64 | $12,022.64 | $32,359.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $19,952.62 / $34,673.69
| Facility | | $16,982.44 | $19,952.62 | $34,673.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $14,454.40 / $19,952.62
| Professional | | $8,511.38 | $14,454.40 | $19,952.62 |