- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,703.72 / $2,703.72 / $3,043.45
| Professional | | $2,703.72 | $2,703.72 | $3,043.45 |
- 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
- $2,530.73 / $2,808.42 / $4,281.07
| Professional | | $2,530.73 | $2,808.42 | $4,281.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,525.48 / $3,141.90 / $4,501.33
| Professional | | $2,525.48 | $3,141.90 | $4,501.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,328.08 / $2,998.37 / $4,599.64
| Professional | | $2,328.08 | $2,998.37 | $4,599.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,703.72 / $2,703.72 / $3,043.45
| Professional | | $2,703.72 | $2,703.72 | $3,043.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,184.07 / $2,998.37 / $4,145.34
| Professional | | $2,184.07 | $2,998.37 | $4,145.34 |