- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $13,489.63 / $16,218.10
| Professional | | $13,489.63 | $13,489.63 | $16,218.10 |
- 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 / $14,454.40
| Professional | | $11,748.98 | $11,748.98 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,542.29 / $27,542.29 / $44,668.36
| Facility | | $27,542.29 | $27,542.29 | $44,668.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,548.82
| Professional | | $1,230.27 | $1,230.27 | $1,548.82 |