- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,310.35 / $5,377.63 / $5,850.98
| Professional | | $4,310.35 | $5,377.63 | $5,850.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,947.92 / $18,838.50 / $22,302.59
| Facility | | $13,947.92 | $18,838.50 | $22,302.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,476.97 / $6,443.49 / $8,921.18
| Professional | | $5,476.97 | $6,443.49 | $8,921.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,701.14 / $7,957.05 / $7,957.05
| Facility | | $5,701.14 | $7,957.05 | $7,957.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,763.49 / $7,957.05 / $7,957.05
| Professional | | $6,763.49 | $7,957.05 | $7,957.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,938.27 / $11,938.27 / $11,938.27
| Facility | | $11,938.27 | $11,938.27 | $11,938.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.89 / $5,667.58 / $8,202.70
| Professional | | $4,466.89 | $5,667.58 | $8,202.70 |