- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,703.46 / $4,659.47 / $5,027.18
| Professional | | $3,703.46 | $4,659.47 | $5,027.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,984.10 / $16,186.11 / $19,162.46
| Facility | | $11,984.10 | $16,186.11 | $19,162.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,536.27 / $5,536.27 / $7,665.11
| Professional | | $5,536.27 | $5,536.27 | $7,665.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,898.43 / $6,042.00 / $6,042.00
| Facility | | $4,898.43 | $6,042.00 | $6,042.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,410.66 / $6,042.00 / $6,042.00
| Professional | | $4,410.66 | $6,042.00 | $6,042.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,870.38 / $4,840.66 / $7,047.78
| Professional | | $3,870.38 | $4,840.66 | $7,047.78 |