- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.42 / $1,755.42 / $2,009.50
| Professional | | $1,755.42 | $1,755.42 | $2,009.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,813.28 / $29,586.39 / $33,362.40
| Facility | | $22,813.28 | $29,586.39 | $33,362.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.89 / $2,822.68 / $4,120.97
| Professional | | $2,349.89 | $2,822.68 | $4,120.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,607.31 / $3,333.07 / $4,664.46
| Professional | | $2,607.31 | $3,333.07 | $4,664.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,419.54 / $3,116.16 / $4,780.35
| Professional | | $2,419.54 | $3,116.16 | $4,780.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.42 / $1,755.42 / $2,009.50
| Professional | | $1,755.42 | $1,755.42 | $2,009.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,394.88 / $3,215.09 / $4,780.35
| Professional | | $2,394.88 | $3,215.09 | $4,780.35 |