- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $13,489.63 / $22,387.21
| Professional | | $13,489.63 | $13,489.63 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Facility | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $14,791.08
| Professional | | $11,748.98 | $11,748.98 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Facility | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $11,748.98
| Professional | | $79.43 | $79.43 | $11,748.98 |