- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,686.25 / $10,686.25 / $12,330.29
| Professional | | $10,686.25 | $10,686.25 | $12,330.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,513.81 / $14,513.81 / $14,513.81
| Facility | | $14,513.81 | $14,513.81 | $14,513.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,595.08 / $14,513.81 / $16,643.61
| Professional | | $10,595.08 | $14,513.81 | $16,643.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,513.81 / $14,513.81 / $14,513.81
| Facility | | $14,513.81 | $14,513.81 | $14,513.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,595.08 / $14,513.81 / $16,643.61
| Professional | | $10,595.08 | $14,513.81 | $16,643.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,864.23 / $17,448.13 / $18,208.18
| Professional | | $9,864.23 | $17,448.13 | $18,208.18 |