- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,205.05 / $5,205.05 / $6,301.73
| Professional | | $5,205.05 | $5,205.05 | $6,301.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,990.11 / $32,409.51 / $36,545.83
| Facility | | $24,990.11 | $32,409.51 | $36,545.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,502.92 / $6,071.81 / $8,938.70
| Professional | | $5,502.92 | $6,071.81 | $8,938.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,205.93 / $6,199.92 / $9,317.28
| Professional | | $5,205.93 | $6,199.92 | $9,317.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,050.89 / $6,505.13 / $9,979.21
| Professional | | $5,050.89 | $6,505.13 | $9,979.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,308.16 / $5,205.05 / $6,301.73
| Professional | | $4,308.16 | $5,205.05 | $6,301.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,037.18 / $6,193.89 / $8,725.66
| Professional | | $5,037.18 | $6,193.89 | $8,725.66 |