- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,103.64 / $6,376.49 / $6,927.83
| Professional | | $5,103.64 | $6,376.49 | $6,927.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,514.96 / $22,305.61 / $26,407.23
| Facility | | $16,514.96 | $22,305.61 | $26,407.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,217.79 / $6,138.58 / $10,266.31
| Professional | | $5,217.79 | $6,138.58 | $10,266.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,756.39 / $8,302.44 / $8,302.44
| Facility | | $6,756.39 | $8,302.44 | $8,302.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,060.78 / $8,302.44 / $8,302.44
| Professional | | $6,060.78 | $8,302.44 | $8,302.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,266.91 / $7,062.14 / $9,712.36
| Professional | | $5,266.91 | $7,062.14 | $9,712.36 |