- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,577.56 / $4,577.56 / $5,589.81
| Professional | | $4,577.56 | $4,577.56 | $5,589.81 |
- 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
- $4,829.78 / $5,434.89 / $8,008.13
| Professional | | $4,829.78 | $5,434.89 | $8,008.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,083.26 / $5,554.28 / $8,348.85
| Professional | | $4,083.26 | $5,554.28 | $8,348.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,525.07 / $5,827.90 / $8,940.31
| Professional | | $4,525.07 | $5,827.90 | $8,940.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,577.56 / $4,577.56 / $5,589.81
| Professional | | $4,577.56 | $4,577.56 | $5,589.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,930.07 / $5,646.92 / $7,711.26
| Professional | | $3,930.07 | $5,646.92 | $7,711.26 |