- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,915.21 / $3,155.15 / $3,957.19
| Professional | | $2,915.21 | $3,155.15 | $3,957.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,433.37 / $12,741.01 / $15,083.87
| Facility | | $9,433.37 | $12,741.01 | $15,083.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,980.41 / $3,506.37 / $5,864.14
| Professional | | $2,980.41 | $3,506.37 | $5,864.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,855.83 / $3,943.38 / $3,943.38
| Facility | | $3,855.83 | $3,943.38 | $3,943.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,878.67 / $3,943.38 / $3,943.38
| Professional | | $2,878.67 | $3,943.38 | $3,943.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,008.47 / $3,810.35 / $5,547.71
| Professional | | $3,008.47 | $3,810.35 | $5,547.71 |