- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,733.07 / $12,959.54 / $16,842.63
| Professional | | $11,733.07 | $12,959.54 | $16,842.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,280.46 / $2,280.46 / $2,280.46
| Facility | | $2,280.46 | $2,280.46 | $2,280.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,688.44 / $1,688.44 / $1,688.44
| Professional | | $1,688.44 | $1,688.44 | $1,688.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,568.60 / $13,275.38 / $14,056.65
| Facility | | $7,568.60 | $13,275.38 | $14,056.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.46 / $13,275.38 / $13,275.38
| Professional | | $1,527.46 | $13,275.38 | $13,275.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.23 / $7,038.14 / $13,679.88
| Professional | | $4,073.23 | $7,038.14 | $13,679.88 |