- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $10,964.78 / $14,454.40
| Professional | | $7,585.78 | $10,964.78 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Professional | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $12,022.64
| Facility | | $11,220.18 | $11,220.18 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $11,220.18 / $20,892.96
| Professional | | $1,288.25 | $11,220.18 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,862.09 / $8,128.31
| Facility | | $501.19 | $1,862.09 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,754.40 / $8,317.64
| Professional | | $3,467.37 | $5,754.40 | $8,317.64 |