- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,733.07 / $15,454.29 / $15,993.39
| Professional | | $11,733.07 | $15,454.29 | $15,993.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,357.34 / $9,084.07 / $9,084.07
| Professional | | $8,357.34 | $9,084.07 | $9,084.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,275.38 / $13,275.38 / $14,056.65
| Facility | | $13,275.38 | $13,275.38 | $14,056.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.46 / $13,275.38 / $25,053.75
| Professional | | $1,527.46 | $13,275.38 | $25,053.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,141.66 / $6,840.12 / $11,583.30
| Professional | | $4,141.66 | $6,840.12 | $11,583.30 |