- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,540.10 / $5,658.08 / $6,162.85
| Professional | | $4,540.10 | $5,658.08 | $6,162.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,691.36 / $19,842.62 / $23,491.35
| Facility | | $14,691.36 | $19,842.62 | $23,491.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,768.89 / $6,786.93 / $9,396.69
| Professional | | $5,768.89 | $6,786.93 | $9,396.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,010.34 / $7,503.37 / $7,503.37
| Facility | | $6,010.34 | $7,503.37 | $7,503.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $7,503.37 / $7,503.37
| Professional | | $5,477.46 | $7,503.37 | $7,503.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,699.85 / $5,934.18 / $8,639.91
| Professional | | $4,699.85 | $5,934.18 | $8,639.91 |