- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,821.91 / $15,821.91 / $15,821.91
| Professional | | $15,821.91 | $15,821.91 | $15,821.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,087.50 / $16,087.50 / $16,087.50
| Professional | | $16,087.50 | $16,087.50 | $16,087.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,625.33 / $22,625.33 / $22,625.33
| Facility | | $22,625.33 | $22,625.33 | $22,625.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,676.02 / $21,676.02 / $22,625.33
| Facility | | $21,676.02 | $21,676.02 | $22,625.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,087.50 / $16,087.50 / $16,087.50
| Professional | | $16,087.50 | $16,087.50 | $16,087.50 |