- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,334.71 / $2,334.71 / $2,623.30
| Professional | | $2,334.71 | $2,334.71 | $2,623.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,783.47 / $23,063.27 / $26,006.75
| Facility | | $17,783.47 | $23,063.27 | $26,006.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,179.62 / $2,426.08 / $3,685.93
| Professional | | $2,179.62 | $2,426.08 | $3,685.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,184.81 / $2,710.88 / $3,883.81
| Professional | | $2,184.81 | $2,710.88 | $3,883.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.43 / $2,581.54 / $3,960.23
| Professional | | $2,004.43 | $2,581.54 | $3,960.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,334.71 / $2,334.71 / $2,623.30
| Professional | | $2,334.71 | $2,334.71 | $2,623.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,195.60 / $2,857.15 / $3,569.92
| Professional | | $2,195.60 | $2,857.15 | $3,569.92 |