- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,150.71 / $4,150.71 / $5,110.33
| Professional | | $4,150.71 | $4,150.71 | $5,110.33 |
- 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
- $4,442.71 / $4,934.60 / $7,269.57
| Professional | | $4,442.71 | $4,934.60 | $7,269.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,174.53 / $5,042.39 / $7,576.00
| Professional | | $4,174.53 | $5,042.39 | $7,576.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,107.74 / $5,290.42 / $8,115.78
| Professional | | $4,107.74 | $5,290.42 | $8,115.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,150.71 / $4,150.71 / $5,110.33
| Professional | | $4,150.71 | $4,150.71 | $5,110.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,134.45 / $5,561.49 / $7,114.86
| Professional | | $4,134.45 | $5,561.49 | $7,114.86 |