- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,151.76 / $9,151.76 / $10,559.72
| Professional | | $9,151.76 | $9,151.76 | $10,559.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,736.82 / $11,736.82 / $13,783.97
| Facility | | $11,736.82 | $11,736.82 | $13,783.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,567.87 / $10,594.14 / $12,512.04
| Professional | | $8,567.87 | $10,594.14 | $12,512.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,736.82 / $11,736.82 / $13,783.97
| Facility | | $11,736.82 | $11,736.82 | $13,783.97 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $6,486.93 / $11,109.25 / $21,680.51
| Professional | | $6,486.93 | $11,109.25 | $21,680.51 |