- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,977.42 / $6,324.72 / $6,756.49
| Professional | | $4,977.42 | $6,324.72 | $6,756.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,106.51 / $21,753.96 / $25,754.14
| Facility | | $16,106.51 | $21,753.96 | $25,754.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,088.75 / $5,986.76 / $10,012.41
| Professional | | $5,088.75 | $5,986.76 | $10,012.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,689.29 / $8,136.27 / $8,136.27
| Facility | | $5,689.29 | $8,136.27 | $8,136.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,939.48 / $8,136.27 / $8,136.27
| Professional | | $5,939.48 | $8,136.27 | $8,136.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,253.60 / $7,261.41 / $9,472.15
| Professional | | $5,253.60 | $7,261.41 | $9,472.15 |