- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,721.40 / $15,721.40 / $15,721.40
| Professional | | $15,721.40 | $15,721.40 | $15,721.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,736.82 / $11,736.82 / $11,736.82
| Facility | | $11,736.82 | $11,736.82 | $11,736.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,567.87 / $11,736.82 / $12,512.04
| Professional | | $8,567.87 | $11,736.82 | $12,512.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,478.66 / $5,478.66 / $5,478.66
| Facility | | $5,478.66 | $5,478.66 | $5,478.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,749.45 / $17,055.89 / $26,930.36
| Professional | | $16,749.45 | $17,055.89 | $26,930.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,478.66 / $5,478.66 / $11,736.82
| Facility | | $5,478.66 | $5,478.66 | $11,736.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,567.87 / $12,512.04 / $19,879.59
| Professional | | $8,567.87 | $12,512.04 | $19,879.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,956.84 / $8,956.84 / $17,167.27
| Professional | | $8,956.84 | $8,956.84 | $17,167.27 |