- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.89 / $1,808.89 / $2,028.65
| Professional | | $1,808.89 | $1,808.89 | $2,028.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39,671.44 / $51,449.63 / $58,015.97
| Facility | | $39,671.44 | $51,449.63 | $58,015.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.95 / $88.95 / $202.14
| Professional | | $52.95 | $88.95 | $202.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,703.75 / $1,896.53 / $2,951.00
| Professional | | $1,703.75 | $1,896.53 | $2,951.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.89 / $1,808.89 / $2,028.65
| Professional | | $1,808.89 | $1,808.89 | $2,028.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,015.77 / $2,884.72 / $3,150.20
| Professional | | $2,015.77 | $2,884.72 | $3,150.20 |