- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,480.26 / $10,480.26 / $10,480.26
| Professional | | $10,480.26 | $10,480.26 | $10,480.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,516.11 / $9,715.23 / $15,544.37
| Facility | | $9,516.11 | $9,715.23 | $15,544.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,715.23 / $9,715.23 / $9,715.23
| Professional | | $9,715.23 | $9,715.23 | $9,715.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,098.00 / $10,216.79 / $17,226.00
| Facility | | $10,098.00 | $10,216.79 | $17,226.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,136.00 / $26,136.00 / $31,471.32
| Professional | | $26,136.00 | $26,136.00 | $31,471.32 |