- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,570.88 / $12,882.50
| Professional | | $3,715.35 | $4,570.88 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $16,982.44 / $19,498.45
| Facility | | $12,302.69 | $16,982.44 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,495.41 / $9,120.11
| Professional | | $4,168.69 | $5,495.41 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,025.60
| Facility | | $4,897.79 | $4,897.79 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $6,025.60
| Professional | | $4,365.16 | $4,365.16 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,025.60 / $10,471.29
| Facility | | $5,128.61 | $6,025.60 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,897.79 / $7,079.46
| Professional | | $3,890.45 | $4,897.79 | $7,079.46 |