- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,120.37 / $2,120.37 / $2,380.03
| Professional | | $2,120.37 | $2,120.37 | $2,380.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,065.14 / $15,647.20 / $17,644.18
| Facility | | $12,065.14 | $15,647.20 | $17,644.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.34 / $2,193.56 / $3,347.50
| Professional | | $1,978.34 | $2,193.56 | $3,347.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.36 / $2,453.53 / $3,515.11
| Professional | | $1,975.36 | $2,453.53 | $3,515.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,820.39 / $2,344.52 / $3,596.62
| Professional | | $1,820.39 | $2,344.52 | $3,596.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,120.37 / $2,120.37 / $2,380.03
| Professional | | $2,120.37 | $2,120.37 | $2,380.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,663.74 / $2,457.17 / $3,241.62
| Professional | | $1,663.74 | $2,457.17 | $3,241.62 |