- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,481.54 / $12,589.25 / $23,988.33
| Professional | | $11,481.54 | $12,589.25 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $16,595.87
| Facility | | $16,595.87 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,022.64 / $12,022.64 / $12,022.64
| Professional | | $12,022.64 | $12,022.64 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.42 / $489.78 / $19,498.45
| Facility | | $20.42 | $489.78 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,882.50 / $17,378.01 / $21,877.62
| Professional | | $12,882.50 | $17,378.01 | $21,877.62 |