- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,924.71 / $41,360.30 / $41,360.30
| Professional | | $11,924.71 | $41,360.30 | $41,360.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,418.01 / $20,069.16 / $20,069.16
| Facility | | $9,418.01 | $20,069.16 | $20,069.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,418.01 / $16,320.44 / $20,069.16
| Professional | | $9,418.01 | $16,320.44 | $20,069.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,992.16 / $19,113.49 / $20,069.16
| Facility | | $7,992.16 | $19,113.49 | $20,069.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,418.01 / $15,062.80 / $20,083.73
| Professional | | $9,418.01 | $15,062.80 | $20,083.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,463.76 / $7,151.63 / $11,020.45
| Professional | | $6,463.76 | $7,151.63 | $11,020.45 |