- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,041.34 / $11,041.34 / $12,740.00
| Professional | | $11,041.34 | $11,041.34 | $12,740.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,847.37 / $13,847.37 / $16,629.97
| Facility | | $13,847.37 | $13,847.37 | $16,629.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,108.58 / $11,945.67 / $14,262.79
| Professional | | $10,108.58 | $11,945.67 | $14,262.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,847.37 / $13,847.37 / $16,629.97
| Facility | | $13,847.37 | $13,847.37 | $16,629.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,108.58 / $13,847.37 / $14,262.79
| Professional | | $10,108.58 | $13,847.37 | $14,262.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,525.28 / $14,417.39 / $26,156.92
| Professional | | $7,525.28 | $14,417.39 | $26,156.92 |